| Occupation as written | Domestic |
| Standardised occupation | DS00: Domestic service - Domestic duties |
| Application received | 18 Dec 1905 |
| Application status | Approved |
| Official | A.H. |
| Date of approval or denial | 8 Jan 1906 |
| If rejected, why? | |
| Birthplace as written | Aix-la-Chappelle, Holland |
| Modern country | Netherlands |
| Age on application | 78 |
| Age on arrival in Australia | 26 |
| Port of Departure | Rotterdam, Holland |
| Port of Arrival | Williamstown, Victoria |
| Date of arrival | 6 Feb 1853 |
| Name of ship | Barque Susanna |
| Voyage | Susannah (1853-02-06) |
| Address in Australia | 4 Laura Street, East Brunswick |
| Address State | Victoria |
| Time at address | 3 years |
| Previous address 1 | Ballarat |
| Address State | Victoria |
| Time at address | 20 years |
| Previous address 2 | Melbourne |
| Address State | Victoria |
| Time at address | 25 years |
| Married | Widow | |
| Children | Yes | 2 sons, one boy living in West Australia, one boy living she does not know, and one girl living in Ballarat. |
| Name of reference | Robert Pulman Lord |
| Occupation of reference | Justice of the Peace (Victoria) |
| Marginalia description | |
| Police report attached | No |
| Link to other applicant | |
| Literate | Yes |
| Reason | N/A |
| Other information |