| Name | George L. Mikacevich |
| Aged | 22 |
| Occupation | Butcher |
| Color | White |
| Complexion | Dark |
| Height | 5 feet, 7 1/2 inches |
| Weight | 140 pounds |
| Color of Hair | Black |
| Color of Eyes | Brown |
| Other visible distinctive marks | Scar over knuckle on left hand |
| Born in | Austria-Hungary |
| On the | 6th day of April, 1897 |
| Current Residence | Church Street, South St. Paul, Minn |
| Emigrated from | Feume, Austria |
| On the vessel | Pannonia (Cunard Line) |
| Last foreign residence | Belovar, Austria--I am not married |
| Renouces allegiance to | Charles, Emperor or Austria, and Apostolic King of Hungary |
| I arrived at the port of | New York |
| In the State of | New York |
| On or about the | 7th day of November, 1912 |