| Regimental number | 19/124 |
| Address | Whangarei |
| Marital status | Married |
| Next of kin | Wife, Mrs Mary Jackson, Whangarei |
| 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 |