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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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Page: of 243
Boarbd or ControL, Form 5
Institution
Application for Admission tn
(Full Name of Institution)
Loeated at
In the matter of the application of ‘ Z ! ~ tLAAJALT......for the admission
child =..to this institution.
Number)
Application is hereby made for the admission to . Moelle §
ull Name of Institution)
ae Soe ..child 44~v..., and in support thereof the following statements are submitted:
(Number)
AGE
Name_ of child : Sex. Place and Date of Birth
tesa é % ‘ Years Months
(Family Name) Given Name
(a) Callow
Status of child SEO, =. Ne te , Half Orphan Acbermetorrect
Has parent or childasa.~ any estate, or are they or cither of them heir to any estate? If so, deseribe said estate, its location and value, including insurance, if any.
H the child.......ever been legally adopted? If so, by whom?
Father’s name io
Place and date of death.
Mother’s name... }
Place and date of death
When and where were parents married?
Where is marriage certificate recorded? CLA
A
Date father came to California %//)Qwi.} PBtoth: rw ats To County?
Which parent is living?....Via4ME _..Habits of sobriety?
Residence of parent ’ Occupation?
Relation of applicant to childhraa
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... 2 $.LaMasoper year. By whom?
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.
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