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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
.
——— sors soo 4
Board or Controu Form 5
Institution
* “i a ee
4Nfifl wation Tor mission in
Z z Z ,
(FullMame of Institution)
Located at : as f
; ,
Py s/f ¢ :
In the matter of the application of Ss for the admission
of ores child =to this institutior
Number
Application is hereby made for the admission to
Full Name of/Institution
i e-sobuld and in support thereof the following statements arc submitted:
Number)
AGI 6 . 7
1. Name of child : = ja) POs Place and Date of Birth
Family Name Given Name sesitts all
5 : Bee ales bpp ets
(a) ¥
a
(b)
(c
(d
2. Status of child Orphan , Half Orphan., Abandoned
3. Has parent or child any estate, or are they or either of them heir to any estate? If so deui,
af
seribe said estate, its location and value, including insurance if any.
. . ‘ 4 ‘
WUethtr ov 7 Ue Poa, foe ie incall Py, v3 uw.' r , ca eo
\
4 : a Vo,
4 the child ever been legally adopted? If so, by whom =
n , i ies ’
5. Father’s name...-}-2.~ 9 Nativity 3 aes ee:
DAF ; ¢ ;
a 1 ¥ ra
12
Place and date of death : beers ‘a aed :
%
14 ) awn os oe
6. Mother’s name sneered Nativity
Placeand—cate—of-death
7. When and where were parents married? mit bes zs
8 Where is marriage certificate recorded? beara ss : a
Lf 2)
3 4 3 a 4
9. Date father came to California? Mother?.-~ “lo County?
10. Which parent is living? : Habits of sobriety? : '
£
11. Residence of parent , nat Occupation ?%e
t
12. Relation of applicant to child H
/ t ates ) , a —
13. Full address of guardian or parent? Sdn Bee sph ere ef : y.. a v
14. the ck inmate of an institution?
15. Name and address of institution? = a : ae 2
perp 2 ee mock . f
16. What amount will be given for aid of child... 2 $..22. per year. By whom?
T Note 1. ‘This application may be used for more than ONE child of one family, but not for children of different families
2 and forwarded at once to Secretary of Board of Control, Sacramento, California.
3 application must be recorded in “R Note 2. 1
A. Carlisle & Co., 8. F
‘orm No. S-APPLICATION FOR ADMISSION TO INSTITUTION
16. What amount will be given for aid of child.
Note 1. This application may be used for more than ONE child of one
Note 2. This application must be recorded in “Record of Orphans” and fo
ly, but not for childre:
ded at once to Se
n of different families.
etary of Board of Control, Sacramento, California.
Form No. 5-—A PPT a mae ~ SC ADMISSION TO INSTITUTT™ 7