| Regimental number | 19/111 |
| Address | Fairfield, Levin |
| Marital status | Single |
| Next of kin | Father, T Hazelhurst, Fairfield, Levin |
| Rank on embarkation | Private |
| Enlistment status | Volunteer |
| Unit name | Samoan Relief Force, Infantry |
| Embarkation details | Unit embarked from Auckland on board SS Talune on |
| Miscellaneous details | Nominal Roll Vol. 1: Infantry/Samoan Relief |