| Name and Surname | Relationship | Age - Years & Months | Marriage or Orphanhood | Birthplace | Nationality | Education | Occupation | Employment | Place of Work | Number & Ages of Living Children under 16 | Language Spoken |
| Jane Elizth. Bye | Patient | 47 - 11 | Single | Middlesex Teddington | Domestic Servant | Rev Street (Private) | 4, Bramshill Road Willesden N.W. |
NB - Other occupants not transcribed.
| Institution | Park Royal Hospital (Poor Law Institution) Acton Lane Willesden NW10 |
| Place | Willesden, Middlesex |
| Registration District | Willesden |
| Registration Sub-district | Harlesden |
| Enumeration District | 82 |
| Schedule Type | lii |
Source: Ancestry - 1921 Census