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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
BoarD or Conrrot Form 5
Institution
Application for Admission to
ah
7
Ss Sf 4 F VM Fr
tA ~
(Full Name gf Institution)
1
J 4 4
Loeated at LTA “ z Ly
In the matter of the application of for the admission
childAccn to this institution
Application is hereby made for the admission to (la Lol ‘s Ah
q Full Name of Institution
/
ry... child A+“, and in support thereof the following statements are submitted:
Number)
AGE
Name. of child ' Sex. Place and Date of Birth
a . Years Months
(Family Name) Given Name
Status of child-¥ cil ...-.Orphan$ , Bet orpimn
Has parent or childAtdae-.....any estate, or are they or either of them heir to any estate?
‘ibe said estate, its location and value, including insurance, if any.
pte
H24.....the child ....ever been legally adopted? If so, by whom?
Father’s name... Ai r ) LA fat Nativity
Place and date of death
pI
Mother’s name...0<_t4 £4 AM.
Place and date of deat é AK AAALGA. 4. ih VA. va ee 3
When and where were parents married ?..4 Lege thtd / Lealy, p27
Where is marriage certificate recorded ?....4 9 is ape oO 7 Lewmiy
Date father came to California? 2£ze, gel LMother? hug. Af 7600 County ?
Which parent is living? Pies (tebe a Habits of sobriety?
Residence of parent : : Occupation?
Relation of applicant to child
Full address of guardian or parent?
the Guid... inmate of an institution?
Name and address of institution?
What amount will be given for aid of child Atete $ PLeavateper year. By whom?
Note 1. This } ion 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 Secretary of Board of Control, Sacramento, Califor
Form No. 5—APPLICATION FOR ADMISSION TO INSTITUTION A. Carlisle & Co., 8