| Occupation as written | aged unable to work |
| Standardised occupation | XX00: Other - Other |
| Application received | 1 Sep 1912 |
| Application status | Approved |
| Official | |
| Date of approval or denial | 4 Sep 1912 |
| If rejected, why? | |
| Birthplace as written | Amt Sorge, Prussia, Germany |
| Modern country | Poland |
| Age on application | 67 |
| Age on arrival in Australia | 23 |
| Port of Departure | Prussia Germany |
| Port of Arrival | Port Adelaide |
| Date of arrival | 15 Aug 1858 |
| Name of ship | Grassbrock |
| Voyage | Grassbrook (1858-08-15) |
| Address in Australia | Woodside |
| Address State | South Australia |
| Time at address | 32 years |
| Previous address 1 | near Angaston |
| Address State | South Australia |
| Time at address | 5 years |
| Previous address 2 | near Eudunda |
| Address State | South Australia |
| Time at address | 17 years |
| Married | Widow | |
| Children | Yes | 5: 1 male and 4 females residing at Woodside, Charlston, Hahudorg off Torrens and Victoria |
| Name of reference | Carl August Klose |
| Occupation of reference | Justice of the Peace (South Australia) |
| Marginalia description | |
| Police report attached | No |
| Link to other applicant | |
| Literate | Yes |
| Reason | N/A |
| Other information |