Name: Peter Hasak, 29 years, born Dec. 25, 1888

Place of Birth: Doborozka, Ung, Hungary (Doboruszka, Ung, Hungary)

Alien, Married with wife and child in Hungary

Current Address: 2638 East 93rd Street, Cleveland, Ohio

Occupation: Laborer, National ?? Company, Cleveland

Tall, stout, brown hair and eyes

June 5, 1917 (signed) Peter Hasak