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Collection: Original Records > Grass Valley Orphan Asylum

Record of Orphans Half-orphans and Abandoned Children (1900-1914 & 1929) (243 pages)

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Dep Pub. Health, Birth and Mort. Div. F. No. 2 ‘ é Brown & Power S. Co. 3 PLACE OF DEATH California State Board of Health e Bureau of Vital Statistios City and County of — DUPLICATE CERTIFICATE OF DEATH San Francisco Local Registered No. e tal a (If death occurred in a Sgr sreeanceenceied ce s hospital or institution, give its namo instead of street it aypehsa 11 id ber, id fill out 2 FULL NAME .. Manuel Marshall NEAR PERSONAL AND STATISTICAL PARTICULARS. MEDICAL CERTIFICATE OF DEATH. 3 SEX 4 COLOR OR RACE . > SINGLE, 16 DATE OF DEATH i =] WOLLS r Wher = (Write the Word) Month 6 DATE OF BIRTH , ue: . HEREBY CERTIFY, That llf Less than = . i day..hrs. se NOS oe e Sea ds.lor..._.. & OCCUPATION The CAUSE OF DEATH* was as follows: Trade, profess! % leningitis Dialer Thing ot woke Le DORE: woe (b) General nature of Industry business, or establishment In which employed (or employer) 9 BIRTHPLACE (State or country) Azores 10 NAME OF FATHER Manuel11 BIRTHPLACE OF ra ania by Pir (State or country) , e 2a : Le 30 an 12 MAIDEN NAME MOTHER a PARENTS ZOre slands *State the disease causing death, or, in deaths from violent causes, b vextnteernts state (1) Means of Injury; (2) whether Acoidental, Suloidal or 13a LENGTH OF RESIDENCE Homicidal. ——$—$<— « vf 18 Special information only for Hospitals, Institutions, Transients At Place of Death 4 or Recent Residents , 9 mon 1 How Long at v3 In California Foner Ot gee. Market Space of eath 2 ea Dale 14 The above Is true to the best of my knowledge ae hoes Pet pontiactedsMarg 41% Anformant) ici Mee Silva 9 PLACE OF BURIAL OR REMOVAL DATE OF BURIAL ie antiead Oakland, Cal. June.27.191.2 20 UNDERTAKER 4 Cunha Caporgno & Bo. ADDRESS 43 }¢4 a: Registrar or Deputy. Oakland, Cal. scribe said estate, its location and value, including insurance, if any. Hed. he child Father’s name LE Place and date of death.. Mother’s name. WAZ, Ys CL Residence of parent Relation of applicant to child Full address of guardian or parent? the child inmate of an institution? . Name and address of institution? What amount will be given for aid of child....... ; Mas ate Abel cli per year. Note 1. This application may be used for more than ONE child of one family, but not for children of different families. : Note 2. This application must be recorded in ‘Record of Orphans” and forwarded at once to Secretary of Board of Control, Sacramento, California. Form No. 5—-APPLICATION FOR ADMISSION TO INSTITUTION. A. Carlisle & Co., 8. F.