Regiment YORK AND LANC.[ASHIRE] REG[IMEN]T. } To be filled in by
12/S37 } Officer in Charge P[riva]te. Verner A. deceased } of Records
STATEMENT of the Names and Addresses of all the Relatives of the above-named deceased Soldier in each of the degrees specified below that are now living.
NOTE. – Against those degrees of relationship in which there is no relative now living the word "none" is to be inserted. If the answers are not filled in, much correspondence and delay may be occasioned by the neglect.
Degree of relationship
NAME IN FULL of every relative now living in each degree enquired for (see note above).
ADDRESS IN FULL of each surviving relative opposite his or her name.
Widow of the Soldier
Children of the Soldier and dates of their births
Father of the Soldier
Spring House. Calow nr. Chesterfield
Mother of the Soldier
Brothers of the Soldier
11 Rushton Road Cobridge Stoke-on-Trent
C. Bryan Dorkin None
Church House, Salford Pris Nr. Evesham
Sisters of the Soldier
Full Mrs blood
M.[?]T. Donkin Mrs Lewis
Church House, Salford Pris Nr. Evesham Spring House, Calow. Nr. Chesterfield
If no Relatives in the degrees above are now living the following particulars should be given:-
Names of those now living.
Addresses in full.
Grandparents of the Soldier
Nephews and Nieces of the Soldier
Uncles and Aunts by blood of the Soldier (not Uncles and Aunts by marriage)
I hereby declare that the above is a true and complete Statement of all the Relatives of the late Soldier now living in the degrees enquired for.
J.A. Verner Signature of the Declarant.
Relationship to the Soldier Father
Address in full Spring House. Calow Nr. Chesterfield
I hereby certify that the above Statement and Declaration made by and signed in my presence is complete and correct, to the best of my knowledge and belief.
Dated at avely this 24 day of July 1919.
Signature of Minister } Edwin E Booker Qualification Justice of the Peace
or Magistrate }
Address sop Main Colly[?] Shirebrooke[?]
5527. W. W88[?]3 GP[?]1[?] 1,000,0 0(S) 2/19 S.O.F.Rd