Explanation of Items on the Certificates
Please note that the blank copy provided on this website is the 1875 version.
To return to the photocopy just click this link.

by DIFFERENT FORMATS

1875 (CHAP 140) = Standard Type
1896 (CHAP 225) = Notation SAME or notation OMITTED or inserted
                                  in italics if new material

(This later form was much more brief and lacked almost all of the intrusive questions meant to explore the inmates' hereditary "predisposition" toward "pauperism".)

[Note: The last Washington County certificate using the original (1875) format was #1622 and was dated 3/29/1901. Obviously, despite the fact that the new form was adopted in 1896, it was about 5 years before it was utilized here. It should also be noted that some form of these certificates (with further revisions) continued to be used until 1920. But since, in this book, we are only publishing information from certificates completed through 1900, we have not included these later forms.]

1.NAME
2. SEX
3. AGE
4. COLOR
5. SINGLE, MARRIED, WIDOW or WIDOWER   "CIVIL STATE" followed by a blank
6. BIRTH PLACE, STATE OR COUNTRY
7. COUNTY
8. TOWN OR CITY)
*********************************************************************
(IF FOREIGN BORN)

9. HOW LONG IN THE U.S.
10. HOW LONG IN THIS STATE
11. AT WHAT PORT LANDED
12. WAS HEAD MONEY PAID
13.IS THE PERSON NATURALIZED
*********************************************************************
(NEW) (IF A WIDOW,) WAS HUSBAND A CITIZEN
(NEW (IF AN UNMARRIED WOMAN,) WAS FATHER A CITIZEN

14.BIRTH PLACE OF FATHER--STATE OR COUNTRY
15.BIRTH PLACE OF FATHER-- COUNTY
16.BIRTH PLACE OF FATHER-- TOWN OR CITY
*********************************************************************
(NOTE: AT SOME TIME, A REPRINT OF THE CERTIFICATE UNDER CHAP 42 REINSTATED THE DESIGNATION OF COUNTY AND TOWN FOR PARENTS OF THE INMATE.)

17. BIRTH PLACE OF MOTHER-- STATE OR COUNTRY
18. BIRTH PLACE OF MOTHER-- COUNTY
19. BIRTH PLACE OF MOTHER-- TOWN OR CITY
20. EDUCATION of Inmate
21. HABITS of Inmate
22. HABITS OF FATHER
23. HABITS OF MOTHER
24. OCCUPATION of Inmate
25. OCCUPATION OF FATHER
26. OCCUPATION OF ANCESTORS AND OTHER RELATIVES   (LIVING OR DEAD)

*********************************************************************
AS TO WHETHER PAUPER OR SELF-SUPPORTING

27. GRANDPARENTS PATERNAL SIDE
28. GRANDPARENTS MATERNAL SIDE
29. FATHER   *(SAME, substituting word DEPENDENT for PAUPER)
30. MOTHER  *(SAME, substituting word DEPENDENT for PAUPER)
31. BROTHERS
32. SISTERS
33. RELATIVES
34. IF A PARENT, HOW MANY CHILDREN LIVING
35. STATE THEIR CONDITION-- WHETHER IN POOR HOUSES, ASYLUMS
36. EXISTING CAUSE OF DEPENDENCE
*********************************************************************
37. WHAT KIND OF LABOR IS THE PERSON ABLE TO PURSUE, AND TO WHAT EXTENT
     (IS THE PERSON ABLE TO PERFORM ANY LABOR)
38. HAS THE PERSON RECEIVED PUBLIC OR PRIVATE OUT-DOOR RELIEF
    -- IF SO, HOW LONG (HAS THE PERSON EVER RECEIVED PUBLIC RELIEF)
39. HAVE THE PARENTS OR OTHER RELATIVES BEEN THUS AIDED
    --IF SO, STATE THE FACT
40. HAS THE PERSON BEEN, HERETOFORE, AN INMATE OF POOR HOUSES
    --IF SO, HOW LONG (HAS THE PERSON BEEN AN INMATE OF AN ALMSHOUSE OR OTHER INSTITUTION)
41. HAS THE PERSON BEEN AN INMATE OF ANY OTHER CHARITABLE INSTITUTION
    --IF SO, NOTE THE FACT (See previous item.)
42. WHAT IS THE PROBABLE DESTINY OF THE PERSON AS RESPECTS RECOVERY FROM THE CAUSE OF DEPENDENCE
43. REMARKS

     (NEW) PHYSICAL CONDITION 
     (NEW) LAST RESIDENCE 
     (NEW) RELIGION 
     (NEW) NAMES AND ADDRESSES OF RELATIVES OR FRIENDS

(end)
1. (SAME)
2. (SAME)
3. (SAME)
4. (SAME)
5.  
6. (SAME)
7. (OMITTED)
8. (OMITTED)
*********
 
 
9. (SAME)
10. (SAME)
11. (OMITTED)
12. (OMITTED)
13. (OMITTED)
*********
 
 
 
14. (SAME)
15. (OMITTED)
16. (OMITTED)
*********
 
 
 
17. (SAME)
18. (OMITTED)
19. (OMITTED)
20. (SAME)
21. (SAME)
22. (SAME)
23. (OMITTED)
24. (SAME)
25. (SAME)
26. (OMITTED)
*********
 
 
27. (OMITTED)
28. (OMITTED)
29. *(SAME)
30. *(SAME)
31. (OMITTED)
32. (OMITTED)
33. (OMITTED)
34. (OMITTED)
35. (OMITTED)
36. (SAME)
*********
 
 
 
 
39. (OMITTED)
 
 
 
 
 
 
42. (OMITTED)
 
43. (OMITTED)