This is the census form for Emily Wilding Davison, who hid in a cupboard in the Chapel of St Mary Undercroft in the House of Commons on Census night 1911. This page shows the enumerator's schedule. You can see her name has been mis-spelt as 'Davidson'.
The form gives the postal address as 'Found hiding in crypt of Westminster Hall.' the pencilled note on the bottom left gives the date '3/4/11 Since Saturday'.
Reproduced with permission of The National Archives.