Form used in 1869, 1870 and 1871
Port of Embarkation Ticket No. Names of Passengers Age of each Adult of 12 years and upwards Married M. F. Single M. F. Children between 1 and 12 years M. F. Infants M. F. Profession, Occupation or Calling of Passengers English Adults Males Females Between 1 and 12 Males Females Infants Males Females Scotch Adults Males Females Between 1 and 12 Males Females Infants Males Females Irish Adults Males Females Between 1 and 12 Males Females Infants Males Females Foreigners Adults Males Females Between 1 and 12 Males Females Infants Males Females Port at which Passengers have contracted to Land