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Service record of a First World War soldier

Army Form W.5080.

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 None  
Children of the Soldier and dates of their births None  
Father of the Soldier J.A. Verner Spring House. Calow nr. Chesterfield
Mother of the Soldier E. Verner do.  do.
Brothers of the Soldier Full Blood A. Verner 36 11 Rushton Road Cobridge Stoke-on-Trent
  Half blood C. Bryan Dorkin
33 Church House, Salford Pris[] Nr. Evesham
Sisters of the Soldier Full Mrs
M.[?]T. Donkin
Mrs Lewis
Church House, Salford Pris[] Nr. Evesham
Spring House, Calow. Nr. Chesterfield
  Half blood None    

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 None  
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

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