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Fifth Census of Canada


Population by name, personal description, etc.
District No.
Enumeration District No.
City, town, village, township or parish

Numbered in the order of visitation
1. Dwelling House _ _
2. Family, household or institution _ _

Residence and personal description

3. Name of each person in the family, household or institution

4. Place of habitation (Township or parish, city, town or village. Range or concession and lot of cadastral number if in township or parish. Street and house number if in a city, town or village. Or other description.)

5. Sex

6. Relationship to head of family or household

7. Single, married, widowed, divorced or legally separated

8. Month of birth

9. Year of birth

10. Age at last birthday

Citizenship, nationality and religion

11. Country or place of birth (If in Canada specify province or territory)

12. Year of immigration to Canada. If an immigrant.

13. Year of naturalization. If formerly an alien.

14. Racial or tribal origin

15. Nationality

16. Religion

Profession, occupation, trade or means of living

17. Chief occupation or trade

18. Employment other than at chief occupation or trade, if any

19. Employer

20. Employee

21. Working on own account. (See instructions)


22. State where person is employed, as 'on farm', 'in woolen mill', 'at foundry shop', 'in drug store', etc.

23. Weeks employed in 1910 at chief occupation or trade

24. Weeks employed in 1910 at other than chief occupation or trade, if any.

25. Hours of working time per week at chief occupation

26. Hours of working time per week at other occupation, if any

27. Total earnings in 1910 from chief occupation or trade

28. Total earnings in 1910 from other than chief occupation or trade, if any

29. Rate of earnings per hour when employed by the hour ? cents

Insurance held at date

30. Upon life $

31. Against accident or sickness $

32. Cost of insurance in census year $

Education and language of each person five years of age and over

33. Months at school in 1910

34. Can read

35. Can write

36. Language commonly spoken

37. Cost of education in 1910 for persons over 16 years of age at College, Convent or University $

Infirmities (Specify age when infirmity appeared)

38. Blind

39. Deaf and dumb

40. Crazy or lunatic

41. Idiotic or silly