Give name and address of count leader, and names of other counters.

请填写调查负责人的姓名和地址，以及其他调查者的姓名。

State whether still on board, landed at (give name of port) or buried at sea.

叙明病人是否仍在船上、在何处上岸（注明港名）或海葬。

Please give name and address of employer. If not employed, please state it.

请将雇主的名字及地址写明。如果失业请注明。