Literal question
<span class="h3">Householder's schedule</span></p>
<p>Prepared under the direction of one of Her Majesty's Principal Secretaries of State, pursuant to the Act of 23 and 24 Vict. c. 61.</p>
<div class="i1">____Parish or Township <br />____City, town, Village, or Hamlet <br />____Street, Square, etc., or Road <br />____Name or Number of House <br />____Name of Occupier</div>