| Date | 1906 Feby 28th. |
| Day of the Week | Wednesday |
| Last Meal before Discharge | B[reakfast] |
| Name of the Pauper | Mayersbach Jane 70 |
| Class for Return for Form A | Not Able-bodied Woman |
| Class for Diet | 4 |
| How Discharged | To Colney Hatch Asylum |
| Parish from which Admitted | Islington |
| Remarks | c/o? Attd Hutton |
Source: London Metropolitan Archives; Reference Number: ISBG/284/19
Source: Ancestry.com. London, England, Workhouse Admission and
Discharge Records, 1764-1930