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Collection: Original Records > Grass Valley Orphan Asylum

Department of Social Welfare - Annual Reports (1928-1935) (190 pages)

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FAMILY HISTORY---Continued ¢ Caco Personal Appearance, mother ......... AIM ML ea een ene en cence ce cece enennnnenetnener anes ranets ieanenneensaensaneeneeenneresnes & ee a Personal Appearance, father ........ tel ENT a7 LA aa OR SEE, YORE ON NEE hea Uae Ued® Irene rahe Ste ROWE, Or crane, eee td “3 RELATIVES NAME AGE ADDRESS SSS ENE Ss . are SER te CR eee ee oer Qa pee eas SS tpt ees ae ae aba cab Sanka gucadvancapyeehacee weaseeeece ( TEST Die Sho i Se) I ee Oe eee ere eer Be dl See ee le ee ere A ee aie geome TP PUP DSPENS Fe (6 LO Baal Pr rine ye As Pe <i OS a oR SS a ee a (ae no Bits Ai Wee etrcd Weer naee de sien iio we ae alse The preceding statements are true to best of my knowledge and I also promise to take back said child in case the i‘ Wassermann Blood Test proves Positive or Suspicious. Signature of Agent Receiving Child. Addtiona! Information: