9
III.
IV.
Date of birth-10th March 18.9.6.
Persons dependent on applicant for their subsistence—
Names.
Relationships
Years of birth,
to Applicant.
Wholly dependent
partially dependent.
or
Darathy Geargina
Robertion
1922
Elizabeth
Robertion 1929.
Daughter Wholly dependent
No. 1.
same
CERTIFICATES TO BE SIGNED BY TWO HOUSEHOLDERS, ONE AT LEAST OF WHOM MUST POSSESS ONE OF THE QUALIFICATIONS SPECIFIED BELOW.
I certify that I have read the statement hereto attached and believe the to be correct, and that I believe the applicant to be in every respect a distressed relative of a deceased
deserving of relief from public funds as Colonial officer.
Signature
Qualification.
Full Postal
off. Walter Field
Householder
18 Glenfull treet
Cheltenham
19 31.
Gloucestershire
Daughter Whally dependent
Date
23 June
No. 2.
V. Other particulars which it is desired to give—
ま
I solemnly and sincerely declare that the foregoing is a true statement
in regard to myself and the persons named as being dependent on me, and that I
have no relatives able to afford me the assistance I require.
Dorothy Robertion Signature of the Applicant.
16 Glenfell Street...
Cheltenham
Address.
NOTE. Where the distressed relatives are miners, application may be made by their guardian on their behalf.
(797)
Pack 9
same
I certify that I have read the statement hereto attached and believe the to be correct, and that I believe the applicant to be in every respect a distressed relative of a deceased
deserving of relief from public funds as
Colonial officer.
Signature-
Qualification.
Full Postal
address
ag South
the Peace for
Justice of St Marys,
Charlton things
Date
June 23
-19 3/
Cheltenha
12
Gloussatiab
** The above Certificates may be signed by:-
1. Justices of the Peace.
2. Notaries Public.
IN THE UNITED KINGDOM.
3. Ministers of Religion acting and resident within the town or district where they attest.
4. Commissioners appointed to administer oaths.
5. Bankers whose names have been returned to the Commissioners of Inland Revenue.
6. Managers of banks and branch banks.
7.
Persons registered under "The Medical Act."
8.
9.
Head Postmaster.
Officers of His Majesty's Naval or Military Services.
10. Member of the Police Force of or above the rank of Sergeant.
IN THE COLONIES.
Any of the principal officers of the Government, Justices of the Peace, Notaries Public,
or Ministers of Religion acting or resident in the town or district where they attest.
ABROAD.
British Consuls, Vice-Consuls, Chaplaine, or Notaries Public.
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