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[Italicised:] Immigration Restriction Act 1901 and Regulations.
[Main heading:] CERTIFICATE OF DOMICILE.
[Two illegible stamps in purple ink.]
[Stamped in purple ink: ‘CANCELLED’.]
[Written in right margin: ‘Cancelled 12-5-05 – N.J.']
I, Clayton J. Mason [name handwritten] Collector of Customs at the port of Fremantle [location handwritten] in the said Commonwealth, hereby certify that Fatteh Mohamed Dean [name handwritten], hereinafter described, has satisfied me that he is domiciled in the Commonwealth, and is leaving the Commonwealth temporarily.
[Handwritten signature:] Clayton J Mason
Collector of Customs
Date[:] 28th Oct 1903[.]
[Heading:] DESCRIPTION.
[The remaining text is a completed form. The questions are typed italicised text. The responses are handwritten in black ink.]
Nationality[:] Indian
Birthplace[:] India
Age[:] 27 years
Complexion[:] Brown
Height[:] 5 feet 9 in
Hair[:] Black
Build[:] Slight
Eyes[:] Black
Particular marks[:] Nil
(For impression of hand, see back of this document.)
Family[:] Wife
Where resident[:] India
Date of arrival in Australia[:] 1896
Place of residence in Australia[:] Perth
Occupation[:] Nightwatchman
Property[:] Freehold property Perth
Date of departure[:] 18th Nov ’03
Destination[:] India
Ship[:] Oceanien
References in Australia (names and addresses)[:] H. R. [?Irving?] Solicitor, Perth
