serial # 1260 order # A 340
Charles Henry JACKSON
perm home address - Leesburg Loudoun VA
age - 43
d.o.b. - May 7 1875
Negro
present occupation - Cook
place of employment - Landsburgh's Dept. Store
Washington D.C.
Nearest Relative - Albert Jackson
Leesburg, Loudoun VA
Chas Henry Jackson (signature)