| Regimental number | 1866 |
| Place of birth | Oakleigh Victoria |
| Occupation | ... |
| Address | ... |
| Marital status | Single |
| Age at embarkation | ... |
| Next of kin | ..., ... |
| Enlistment date | |
| Rank on enlistment | Private |
| Unit name | 14th Battalion, 4th Reinforcement |
| Embarkation details | Unit embarked from Melbourne, Victoria, on board HMAT A9 Shropshire on |
| Miscellaneous details (Nominal Roll) | see other |