serial # 1301 order # A 297
Samuel JACKSON
Perm Home address - Purcellville Loudoun VA
age - 38
d.o.b. - February 7th 1880
negro
present occupation - Farm hand
Employer's Name - W.O. Whitman
place of employment - Purcellville Lou. VA
Nearest relative - wife - Edith Jackson
Purcellville VA
Samuel Jackson (signature)