| Address :- | 12 Denbigh Ter, W11 |
| Name | Rel | Age | Sex | Marr | Birthplace | Nationality | In Education | Profession / Trade | Employment | Place of Work | Children <16 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 |
| Samuel GOATES | Head | 43y 09m | M | Married | Bishop's Stortford, Herts | Baker | A&M Rodwell | 59 Pembridge Road | None | |||||||||||||||||
| Edith Lucy MOULDER | Housekeeper | 34y 04m | F | Single | Kensington W | Home Duties | Private |
| Number of Rooms | 3 |
| Signature | Samuel GOATES |
| Postal Address | 12 Denbigh Ter, W11 |
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