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Form 500 A Department of Commerce and Labor IMMIGRATION SERVICE

Saloon, Cabin, And Steerage Aliens Must Be Completely Manifested. 

List Or Manifest Of ALien Passengers For The United States

Required by the regulations of the Secretary of Commerce and Labor of the United States, under Act of Congress Approved February 20, 1907, to be delivered . . . 

S.S. [Steamship]: VADERLAND, sailing from ANTWERP 25 MAI, 1912

1  Number on the list: 24

2  Name in Full. Family Name: Zlocsewer   Given Name: Chawa

3  Age. Years: 18 [sic]

4  Sex: F[emale]

5  Married or Single: S[ingle]

6  Calling or Occupation: Tailoress

7  Able to -- Read: Y[es]   Write: [Yes]

8  Nationality. (Country of which subject.): Russia

9  Race or People: Hebrew

10 Last Permanent Residence. Country: Russia   City or Town: Mlawa

11 The name and complete address of nearest relative or friend in country whence alien came: father Josef Zlocsewer Mlawa - Russia

12  Final Destination. State: NY   City: NY


States Immigration Officer At Port Of Arrival

to the United States Immigration Officer by the Commanding Officer of any vessel having such passengers on board upon arrival at a port in the United States.

Arriving at Port of NEW YORk 4 JUIN 1912 

13 No. on List: 24

14 Whether having a ticket to such final destination:  --

15 By whom was passage paid? (Whether alien paid his own passage, whether paid by any other person, or by any corporation, society, municipality, or government.): uncle

16 Whether in possession of $50 and if less, how much? $23[?]

17 Whether ever before in the United States and if so, when and where? Yes/No: No   If Yes--Year or period of years.  Where? 

18 Whether going to join a relative or friend and if so, what relative or friend, and his name and complete address: uncle: Isidor Meegdall, Westchester, NY

19 Ever in prison or almshouse, or institution for care and treatment of the insane, or supported by charity? No     If so, which

20 Whether a Polygamist? No

21 Whether an Anarchist? No

22 Whether coming by reason of any offer, solicitation, promise, or agreement, express or implied, to labor in the United States: No

23 Condition of Health, Mental and Physical: Good

24 Deformed or Crippled. Nature, length of time, and causes. No

25 Height. Feet: 4  Inches: 11 

26 Complexion: fr [fair]

27 Color of -- Hair: br [brown]  Eyes. " ["gr" (green)]

28 Marks of Identification --

28 Place of Birth. Country: Russia City or Town: Mlawa