Permanent Address: Hendersonville, Sumner, Tenn.

Age: 35

Date of Birth: October 1, 1882

Race: White

U. S. Citizen: Natural Born

Present Occupation: Merchant

Employer's Name: Self

Place of Employment or Address: Hendersonville, Sumner, Tenn

Nearest Relative: Mrs. Sophie A. Bloodworth, Hendersonville, Sumner, Tenn

I affirm that have verified above answers and that they are true:
Samuel Sumner Bloodworth

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

Remarks: Blank

Date of Registration: Sept 12, 1918