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

MARGIN RESERVED FOR BINDING WRITE PLAINLY WITH UNFADING !NK—THIS IS A PERMANENT RECORD PHYSICIANS stated EXACTLY. AGE should be , that it may be properly classified. 3 “e B a 3 a pi oe 2 ° 2 w ° o 2 = 3 ° es G < ° S © £ ° = i e 3 = ° a > [2 5 > a I th Exact statement of occushould state CAUSE OF DEATH in plain terms tructions on back of certificate. See ins pation ts very important, California State Board of Bealth 1 PLACE OF DEATH County of Nevada STANDARD CERTIFICATE OF DEATH CITY OF GRASS VALLEY 2 FULL NAWHOr McLeod, PERSONAL AND STA TISTICAL PARTICULARS { COLOR OR RACE 5 Single, Married, Widowed, or Diyngeetr ied (Write the word) white Female “3874 (Month) (Year) LESS day, or (Day) If than 1 hrs. . min? 8 OCCUPATION pa le, profession, House wife al nature of Industry, or establishment in ich employed (or employer) BIRTHPLACE (=tate or country) -10 NAME OF FATHER BIRTHPLACH Trance OF FATHER (State or country) ? MAIDEN NAMBQ not Ow, OF MOTHER Know > BIRTHPLACE OF MOTHER (State ness, New Jersey John Bassette— PARENTS _ Do not Know or country) LENGTH OF RESIDENGE At 4 years 14 The Abo, Is True fo t t My Knowled Wofuios" as Webeda”” ee Grass Valley Cal,” Place of Death years, months in California months (Address) fed UD Lite so Subregistrar 1916. PL Registrar or Deputy illy adopted ? ‘ather’s name lace and date of death Mother’s name and date of death lace When and where were parents married? Where is marriage certificate recorded ? f applicant to childéz address of guardian or parent? child inmate of an institution? the Name iddress of instituti and What amount will be given for aid of child RUREAU OF VITAL STATISTICS, March’ 10; 1915; State Index No.. Local Registered Nov. (If death occurred in a hospital or institution, give its NAME instead of street and number, and Ee, out No, 18.) "MEDICAL Wisp ped: ‘16 DATE OF BER en March ase bie. 25. Ss I HEREBY CERTIFY, THA attended deceased March a 415 March “6; 191 tPOmr.c S80 March 6, 1915" eee BVO: “Of 17 e. . . that I last saw h and that death occurred, . The CAUSE on the date stated above at OF DEATH © was as follows: (Duration) Contributory . (Secondary) (Duration) iste 8 Brown mos., Grass Vali” 191. (Address) or in de aths 1 from VioDeanne Causing Death, and (2) whether Aclent Causes, state (1)Means of Injury; . cidental, Su al. or Homicidal, 18 SPECIAL INFORMATION only for Hospitals, Institutions, Transient, or Recent Residents. ‘State the How long at Place of Death Former or Usual Residence Days contracted, ath? Was disease at place of d 1s PLACE OF BURIAL OR REMOVAL Date of Burial City Cemetery March 9 1915 Where Ty not 20 UNDERTAKER Address Thomas M. Harris Grass Valley Ly hs a heb Habits of sobriety ? 9 Occupation per year. By whom?

MARGIN RESERVED FOR BINDING WRITE PLAINLY WITH UNFADING !NK—THIS IS A PERMANENT RECORD PHYSICIANS stated EXACTLY. AGE should be , that it may be properly classified. 3 “e B a 3 a pi oe 2 ° 2 w ° o 2 = 3 ° es G < ° S © £ ° = i e 3 = ° a > [2 5 > a I th Exact statement of occushould state CAUSE OF DEATH in plain terms tructions on back of certificate. See ins pation ts very important, California State Board of Bealth 1 PLACE OF DEATH County of Nevada STANDARD CERTIFICATE OF DEATH CITY OF GRASS VALLEY 2 FULL NAWHOr McLeod, PERSONAL AND STA TISTICAL PARTICULARS { COLOR OR RACE 5 Single, Married, Widowed, or Diyngeetr ied (Write the word) white Female “3874 (Month) (Year) LESS day, or (Day) If than 1 hrs. . min? 8 OCCUPATION pa le, profession, House wife al nature of Industry, or establishment in ich employed (or employer) BIRTHPLACE (=tate or country) -10 NAME OF FATHER BIRTHPLACH Trance OF FATHER (State or country) ? MAIDEN NAMBQ not Ow, OF MOTHER Know > BIRTHPLACE OF MOTHER (State

ness, New Jersey John Bassette— PARENTS _ Do not Know or country) LENGTH OF RESIDENGE At 4 years 14 The Abo, Is True fo t t My Knowled Wofuios" as Webeda”” ee Grass Valley Cal,” Place of Death years, months in California months (Address) fed UD Lite so Subregistrar 1916. PL Registrar or Deputy illy adopted ? ‘ather’s name lace and date of death Mother’s name and date of death lace When and where were parents married? Where is marriage certificate recorded ? f applicant to childéz address of guardian or parent? child inmate of an institution? the Name iddress of instituti and What amount will be given for aid of child RUREAU OF VITAL STATISTICS, March’ 10; 1915; State Index No.... Local Registered Nov.. (If death occurred in a hospital or institution, give its NAME instead of street and number, and Ee, out No, 18.) "MEDICAL Wisp ped: ‘16 DATE OF BER en March ase bie. 25. Ss I HEREBY CERTIFY, THA attended deceased March a 415 March “6; 191 tPOmr..c S80 March 6, 1915" eee BVO: “Of 17 e. . . that I last saw h and that death occurred, . The CAUSE on the date stated above at OF DEATH © was as follows: (Duration) Contributory . (Secondary) (Duration) iste 8 Brown mos., Grass Vali” 191.. (Address) or in de aths 1 from VioDeanne Causing Death, and (2) whether Aclent Causes, state (1)Means of Injury; . cidental, Su al. or Homicidal, 18 SPECIAL INFORMATION only for Hospitals, Institutions, Transient, or Recent Residents. ‘State the How long at Place of Death Former or Usual Residence Days contracted, ath? Was disease at place of d 1s PLACE OF BURIAL OR REMOVAL Date of Burial City Cemetery March 9 1915 Where Ty not 20 UNDERTAKER Address Thomas M. Harris Grass Valley Ly hs a heb Habits of sobriety ? 9 Occupation per year. By whom?