454
FEDERATED HALAY STATES 710075" & ORPHANS' PENSJON SCHLME:
istered No:
Initials)
of Officer
Bachelor, l'arried)
Widower, or Widow (and/or orphana) drawing pension 31st December..........
of Birth
of Entry
of it
HISTORY OF THE OFFICER:-
age at which contributions)
cease to be payable Cause of Exit
nt of yearly contribution paid at Entry
Increase Decrease
Amount and Date of each Increase/Decrease in Contribution during membership:-
Date Increase Date (Increase Date Increase Date Increase
Decrease
Decrease
Decrease
Decrease
HISTORY OF THE VIFE OR WIVES:-
Birth
Date of
Marriage
Divoros
Death
SENEST
HISTORY OF THE CHILDREN OF PENSIONABLE STATUS
ON THE 31st of December
2nd Family
3rd Family
4th Family
Sex
Date of
Sex
Date of
Sex
Date of
Sex
birth
birth
birth
1st Family Date of Thirth
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