Permanent Address: 4 Bethpage, Sumner, Tenn.

Age: 41

Date of Birth: Aug 4, 1877

Race: White

U. S. Citizen: Natural Born

Present Occupation: Farming

Employer's Name: Blank

Place of Employment or Address: 4 Bethpage, Sumner, Tenn

Nearest Relative: Georgie Adcock, 4 Bethpage, Sumner, Tenn

I affirm that have verified above answers and that they are true:
Rubun Adcock

Registrar's Report
Height: Medium
Build: Medium
Color of Eyes: Brown
Color of Hair: Brown

Remarks: Blank

Date of Registration: Sept 12, 1918