Formulaire utilisé en 1869, 1870 et 1871
(Disponible en anglais seulement)
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