|Present Relief| | Names of| Date| |______________|The circumstances No. I |Dependent| of |Residence|Money. | Bread| | Family. |Birth| |s. d. | lb. | |_____|_________|_______|______| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | The cause } | and date of } | first } | application. } | | The FACTS of } | the history of } | the case, } | abstracted to } | the date of } | the last visit } | | | Relations who, } | according to } | law, should } | assist. } | | Friends who } | do assist, or } | are likely } | to do so. } | | |The circumstances as Orders of |they existed when the Board, |visited by R. O.,&c. and Remarks | ___________ | |Visited Dec. 16, 1846. | | |Visited, &c. | | |Visited.