u vl:.\,.,· ....

l"\nl"\ I IV''II rvn vrU\A1J~

Child or Children under SiXteen Years of Age Surviving.

.....
,,,;1
~\""
rCl'11<:)lVl'll vr 1"\ VV IUVVV-\.
'UI

I!Iiir This paper MUST be sworn to before·the Probate Judge or Clerk of the Court. ""fiM

, ­
thm,h, has not "_mam'd~na/~d&alk1~~~fid" .
.. ; that the following are the names and dates of birth of all of said soldier's

HIS BY A FORMER M.HlRIA';E.

. . . . .. /'orll ........ _.... . . . . . . . . . . . . . . 1'. -------------- ~ -~----------. Lorn __________ "" _______________ ..
____ l~ __

That she has not abandon.ed th~ support of any of his children, but that they are still under her care or maintenance.s

-- -- - --------------- -- - -~ --- ---- --- - --- -- --- ---- - -- ---- --­

 (/ . ; ~

DJ!CLHRHTION FOR jt!IDOlV'S PENS]ORr J";

ACT OF JUNE 27TH, 1890.

That she is without

sufficient means of support other than her daily labor. Th th€ names and dates of birth of all the children now living under sixteen years of age of
the soldier (or sailor) are :IS follows:

...........~u:2.Lk: . . . ,'Y=:' born ........ 2;;:l.u-L~. . .1/.. . . . . . . . . . . . . . .

born ....... , 18......

... ............... .•. .... .... born ....... .......... ... .................. ... ........... 18

Th".fl<' ...... P""'""',,"',, ;0' "'""" h" b"'~fil'd zf!t ~L~ QdcJz£L.L/.
·::2~~~i;;;;";~;;,~:i;;:;(;;,f:?;;?';;;;;i,;,, ..."",.•"'" ,", ;;;,;;,.';h;;;;'~.;.';';;';; ;;;;;~,,;. ......... ....
That she makes this declaration for the purpose of being placed on the pension roll of the United States unde, the provisions of the Act of June 27,

She hereby appoints, with power of substitution, MIL 0 B. S T EVE N S & CO., of .. Cl!!ftAI.'6itHt(,.. @i!t:;.~;.
their successors or lA~al representatives, her true and lawful attorneyS to prosecute her claim and recei ve a fee of Ten Dollars. Thn t her post office
~.- .
('dd'=""~2'(~a/ .......................

~.LlUnty
\....... of.
~
_ .... ...
-)

p.&~~... ". . . . . . .. .• State of... dT~_a.<7CC·~

'4... . . . :Li~. /..~C~~ ,~_{ .. v/t/)11.~/ . 11: j£/lrt'i4:!

'Sit(n .. tur~ of C\';).';m:\nt

. . JJ.l..... . dJ~. .:;lt..~.~4l1~:~.

Two witness#3 who can "rite:, s.ign hete.
SEE OTHER SIDE.
 •
"

.- '.. t-_··
&T. f\uGulir'Ni,s @HURCH:·
.
REV. J. L. BRASSART.

PERRY COUNTY.

Q
 REV. J. L. BRASSART.

PERRY COUNTY.

/~

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 ."....... , lUi:

f - A ..... ' ~tlHl· uf

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j
('Olllll,\ uf I. '.,." .. ~tal(' "f .I.

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day of j
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7
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• !tOO; a ~. ~ \ ... in t. 0 I /'

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. ttt'j..rimt'llt or ~ .,.. I.,j/' '"
.J, ill the "ar of )~GI.
o /'

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Jf. .\\' a ... Ilt'\'cr in t lw m iiitfl.I'Y or nn ,'nl 8t'rdc(' of tilt'

"
I'nil<"\ Stak, priu]' to ( " i" /
,\ 11\1:' 81 ne;: .. . : . I. /

J,
thb auplk:tat ha~ rc ... iued iu the . / •. of ~ nnd his U('I.·u})4Itioll has bel'll

tu jJfoSpl.:uh: ldt

claim. \'rith full }>o\\"I...·)'!lf ~Hlhtitntiu!l~ that h-j..; vo",tnfill't' is at • ~t"t(. "f 11 4
I
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ATTl.'··T.

"'(Y , , / ' , ' / /.~ I

,\ b, 11t'1',,,,,,,II, a Pl",,,,.,,d ,c-,/t!£:'t~.t' . to.,.. &1?!?::7~~.:1, .re.iding atY~~:'/Z:C: 1,

"c"j(lill;:' at a-c-r:t!e.~" " 1'l'1"'Jll' \\h~1 I ,clufy to lH'le81'('(tahle .,,"\ ('Illith',\ t" ,·",·uit. and

/' /' AC/j/ A /

wen' 1" ",,·,,1 "wi "aw, "~li.t/'.£.d.t:t../ t/U;'j;~t/ / r , til,> claimant. ,igll Iii, '''lin" '0" 111 "k,' 1", lliark) to 11,,'

h1reg'uing: tlt'daI'Hiioll: lhat iht'Y havt' VVt'I'Y l'l':l!'5QB tll iH'licH'~ frullI llll' Upj)t'fiHUH'C of r-.aid claimant and tllei,' :\"ljl;ailIlIiIH'l' \\ it}) lliHl, ~llat tH' i~ thl' idl'lltkH 1

.... ,ht~" of

e!..'l'tify that tlll't'uBtl'nHuf thl' a1>on.:' (\Pelal'ation, etc.. wen' fillly madt, kllown HHd (·xpilline.i to tlw nplllicaut <lIHl wil­

a,hled: ant! tll"t 1 ilUH' uo interest, direct or huH,·t'ct, in tile rroser~iull of thio e~
I

L
\
 ,

READ THE INSTRUCTIONS ON BACK OF THIS BLANK BEFORE USING IT

3-044

APPLICATION FOR REIMBURSEMENT

This form not to be used if the deceased pensioner left a widow or minor children under sixteen years of age

STATE OF------------~---------------}88:
COUNTY OF______________ ~---------- ______•_______________ _
On this______ ?___________ _ _ _______________, A. D. 1930. before me, the undersigned, personall • appeared
~~u:a..~~I!::a:~..c:....~_c:---. _ __, aged ____________ years, a resident of ______ ~-- ' _____________ ,

f.l.:::....~~r:~'l:- .. -----------, State of -------..c./~, who makes the following

application for, and claim i eby made for, reim~Be~t fro?e accrued pension for expenses paid (or obligation incurred) in the
las¥,ckness and burial oL _ ~:~ _______ , who was a pensioner of the United Stat~ cert~te
No. _~Z~_.l.3. __ , and who DIED ____ ~-.L--~-, 19-~4 &t---;---~--~-r---.?'f~--!---
and was buned at -~-.. -- - - - -----~7---c.!J~1 ~.
That the answers to estions propounded below are- full, c~ete, and truthful to the best of my knowledge, information, and
belief, and that no evidence necessary to a prope~ adiustmen~f_ all clai~s .,ainst the accrue~~r withheld.
1. Wbat was the full name of the deceased pensIOner? ----~----d.---- _ __ _______________________
2. In what capacity was decedent pensJoned? (As soldier or sailor, or as a widow, minor child, dependent relative, etc.)

----------~-.-a----~--------------------------------------------------------------------------------------------------
3. If decedent was pensioned as a soldier or sailor­
(a) Was he ever married? (Answer yes or no.) ___"________________.::::::". ____________________________________________________ .________________________ _
(b) How many times, and to whom? ____ u u ______ u _ u _ u u n ___ n _ _ n " "_ _ _ _ _ _ _ n n _ n _ _ _ _ _ _ _ _ _ n n _ _ u u _ _ _ u n _ _ u _ _ u n _ _ _ _ _' u _ n _ _ _ _ _ u ____ n __ u _ u u

(c) If married, did his wife survive him? (Answer yes or no.) ________ um_?:'~u_u __ m
_ u __ m ______ m ____ m _ u n u n __ n ___ m _________ n __ n

(d) If so, is she still living? (Answer yes or nO.) ______________________ n ______ "=='___________________________________________________________________ _
(e) If not living, give full names and dates of death of all wives___________ -====_________________ u _____________________________________________ _

(J) Was he ever divorced? (Answer yes or no.) _____________________________ =:::.________ .____________________________________________________________ _
(Il) If so, is the divorced wife still living? (Answer yes or no.) _______::-::::-::::_________ (If living, a copy of the decree of divorce must
be filed.)
(h) If not living, g-ive her full name and the date of her death_______ m _____ m _ u - = = __ m m m ___ n u __ m _ m __ m _ m m n _______________________ ___

4. Did pensioner leave a child under 1G years of age? (Answer yet: or no.) _______ ~--------------------- .. ------------------ _____ ._______ .__ _
5. Is any such child s/'illlh-ing; (Answer yes or llO.) ________ m __ m m n ________ u _______ .::m_________ m _ _ _ _ _ _ _ u _____ u ____ m _______ mmu __________ n ___ _

6. 'Were any sick or death benefits paid on pensioner's account? If so, give name of society aud amount paid_________________________________ _

-------- --------- -- --_.-- --------- ----- ----~------------- -- ------ ------- -- --------------------- -----_.------- --- ---_.------------- -- ----- - ----- -------------­
7. Was there insurance (life, accident, or health) in force on life of pensioner at time of death? (Answer yes or no.) _______~----------
8_ If so, give the naIile of each company in which a policy was c.arried and the amount in which each policy was written____________________ _

9. 'Vho was th e beneficiary named in each policy?_. _______________________•____•________...________________________________________________. ______________________ _

10. 'Vhat was the rclaiion of eaen beneficiary to the pensioner?______•________••________________.____. _________ . _____________________________________________---_
II. Were the premiums paid by the deceased pensioner?_m__ m __________.. __ ......-::"______________::._______ m ___m ______. ______________________________ m ____ _
 -----_. --- --------- -------~- ---- -. ----. --._., --'" -._-- --- --------------_ .. --- -----.----- ---- --_.... ---- -..---- -------.- --.. -_..------- ---- .. __ ._.... -_.- ----­
14. Di1 tho doo..... pention~ 1M.. ~y mon,y, ,~I ..ta"]!J::~pe2.--~2=------'--~;;;;;;;:'
~"':::::2~U' -~-:::-::---.?::ia.~~::::=~-::::::~:~:::--;-"k--:---L.
y
15. If of _n,noh P'OPorl _-___

16. What was e assessed value (last assessment) of the real estate?___ ~-_~~II!:.1f':~_~~ __ ¥.:-¥.:l2 ,

17. HO_W_ =_th'=i~n-,~~,_p~O::_~i'~'~_~,,::::::=::_:2"':: _ _ _~~:~:::'::::::-:::::::::::::::::_:::::::::=::::

18. Did pensioner leave an unindorsed pension check? (Answer -es or no.) ______ ----- ••--.-------...• --~-- •.--- ....••.•-.-......--•.•-.-••­
19. What was your relation to the deceased pensioner?.__:_ _ ____.._ ____ __.___... __. ______ £_.___.._._._____________._.._.....__..__..____.__
20. Are you married? (Answer yes or no.) •__..•.•._.._•.__••____ ~--- _____________ •__•_________________________..__ •_________•______•. _. ________. ________•____

21 "'bat was the cause of pensioner's death?_____________ __ _ _ _____ . ________ .. _. ______________________ .____________ .________ •.

22. When did the pensioner's last sickness begin?_.______ ._._... _m - .--. . . 2..--~___ ~f--e..--~
23. From what date did the pensioner become so ill as to require the regular and daily attendance of anot eT person constantly until
death7_____.________.______•__ •__ •____._•. ~~.-----~---- __ .2._.a_/_.__ L'?~_t2---.---::--.-..--.--.-...
Gi~:.~~_~.~::.~_~n~~~.;;.~~-~ss of eac~ P_hYSic~.n ~~~_;:~~~U2-~Uring-la~t s~~~~;_~~£~~~~~
24.

----~,,--------:---------. ----~------------
---------------------------- ----------
25. State the nam.es of the persons by whom the pensioner was nursed during the last sickness.•._•._. __.•..••_._...._._. _______.•_._.__________•____ ..
------------._-----------------­

:~--: ---:---~3!;:::~ --:~-:~z.

26. Where did the pensioner live during last sicknessL~.~_m__ . m_.__ m ___~_.~~._ .. ~ "
27. Has there been paid, or will application be made for payment to you or any 0 her pel1!on, any part of the expenses-~f & pensioner's
last sickness and burial by any State, county, or municipal corporation? (Answer yes or no.) __ .~ .._-::::. ___ L_~t2._:__ ~
The following is a complete statement of aU the expenses of the last sickness and burial of said ~eased pensioner:
(Eacb charge entered below should be supported by an ite!llized bill of the person who render"" the sem"" or ft:t.rnlshed any supplies for which reimbursement Is demanded
and should show, over his signature, by whom paid, or who is held responsible lor pa;-:roent, a.nd oontain the name of the pensioher for whom the expense was incurred or service
rendered. If DO cJw:lle was made for any item, that lact should be indicated.

NAMES

. - .-. - -. . - -.-. _=-.

:t\A TURE OF EXPENSES

~ -;~~~~:~~-
ST ATE WHETHER
PAID OR UNP.'I.lD

-tP~. _...._.2_.5._'__..!!.P
AMOU:t\T

~::~~~:::::==::::=::==:=:::. :::::::;:--~-=~--::::::----:--::::::~~;:::k:2:jj:: :~

~--~.-.a..- . -.-- . ______ . ._......... Underta.ker._•••.•_.___••_._••••••.•• ••••••(f'~ ...._._I_..2.l.Q.__ ...__.

Livery____•••____.•___••_••.•_•.••_ .. __•••• _•••_••••__.•_ •..___ ._1.._......__....___,._

I
___. ________•__•___•___•__ . __ . ___. __ . __•______. ___________ .. ______ __ ___ _____ Cemetery____________________________ ... _______________________ I.
.. ________ ". ________________ .•__

Other expellSM a.nd their nature: j

That of the above-mentioned expenses this claimant has paid"; o? guaranteed the payment of, the following Items: ___.______. _____•___
who, being duly
the following questions are true:
1. Did pensioner (if a soldier or sailor) lea.ve a widow or a minoe' child under age of sixteen years survivillg'~

= ......- -..... ~ --- -- ------ ---- ------ ----- --- -- -- -- --- ---- ",'. --- --- --------- ---- -------- ---- ------,
2. Wh" did
th' p",ion" di,L............. ..
~

. ...... L.... ,.. .......L..? ....~ .....:...~

/ .~

3. Di~="1~n~T'ZL.:.•:d2d.:~; . :~. . . . .: .....

-------~-3-b-t2--L-------------------
4. Our means of knowledge of the above statements made by us ure: We kr:ew t~e \!i1r:eased pensioner for__ 3(1.__ ycars and____/f'-O__

:.:;~~:j~:~~~.:::::~::;~i~~~~~i;":~~~
-6.._____________
Subscribed and sworn to befte me, thiL____ day oC___________ _ _ _____________________________________
A. D. 19_..14' '
and I certify that the contents of the foregoing application were fully made known and ained to the claimant and witnesses before
swearing, that I have no interest, direct or indirect, in the prosecution of t lis claim, an I further certify that the repubtion for eredi­
bility of the witnesses whose signatures appear above is___ ___.~~~2':':~'C.

Give name of any other physician who attended the pensioner in last sickness____ ~-----------------------------------------------

··;:L?g:i·z.·~.'n: '".t':.'::;;;""t. .
. __________________________________________________ . 19 _____
-a2- - - - - - - - - - _ _ Y7k___~------- Attending Physician•

6-1672 A.ttending Physician.

!IIi.·

~ . ----­.. - - - - - - - - - - - - . - - - - - . - - - - = : = - - - = . - - - - - - - - -..- ­..-

 :MEDICAL DESCRIPTI V ~ .Ll~

Ward . . {Bed~ Gener"ft,'Pi;al a~~_~ ___

Nam@ji~ ~{/(Jf~ .. Age . ......... ,Rank . /MM.k , 0Ij:4£'1. Regiment •....... .(.~_
. Lor 11 . ~ d: - . J If Admi.ssion~.Mjl.... /L4d!.... . . . . . . . . . . . . . _.. . . . . . . .
Dlse se or Injury, 1.1:.. u~. ;;!......~. Return to duty, cured, .It{..CiA..(2,:I.Y..tfh... Lt[/;!: ...
Result,....................................................................................................... I p, l h "­

j D::c~,!g: ;;~;~~;,,:e,::.::::
I Nomoo' .............1omOM.]

M J./?- /I/
.......................Lk!.......z:r.......~._~~.................

i I 1­
DATE OF

l Transfer to anoiller Hospital, ···"·.··..,.. ··.·H·.. ·····.···················~~_

NOTE.-Whcn6 ~en:
is : t ' r : : Z :6 G:k:Piial. the entries on
cOllelition will be noted on it, (in ink,) from tiIne to tilLe, by the
thi,~:~C:ti~~·~ist·~111~·e~o~~e~~~~
... AlI important
in cha.rge of ,:'e ·Ward. When the patient has been wounded, the d;lte and chamCler
Cban~~~":~'~i~
of the wound will be stated, the nature of the operation, (if abo>'e all, the result. In case of transfer, this Ii,t will be sent. through the Offi~er in
charge 0 the transportation, or failing one, by mail, to the Surgeon in cbarge of tbe HOi;pi!31 receivil:!j' Ihe patient. \Vhen this lI1euical History shall have
been completed, by tbe cure, di~charg!;l, furlough, or death of the patient, it will, with the treatment and result, carefully noted, be transmitted directly to th6
Surgeon General.

DATE. TREAnIE~T. I DIET. RE)'IARKS AS TO CO~'1)ITION OF PATIENT, &c.

I
----------------------------------

/t?Y-t
 OASUALTY SHEET.

J{ame,~~_ ......
Rewk. ~---_. Company I ,Regiment, ?/.~

Arm.. '~--"~"""". State, ............. ~~ ..._............____...

Place of casualty, ~~~ .. u ..._u._ .•... h __ h _ _ .h

••••••••••••••••••••••••••••••• h • • • • • • • • • • • • • : • • • • • • • • • • • • • • • • • • •; ; ; : ; • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Nature of casualty, £'~~~. ..&:~.u._.;>_ . _.. . . . h •• h . h •• U •••••• m

. .

fROM WHAT SOURCE THIS INFORMATION WAS OBTAINED

. RCp01·tOj' ICillerl. -ff'uunrirrl, (1 nd .llfissilJ,Q of 'lie 21'/ ('ld,

j1 Brignde,/. Division. ~ .... u •• Corps, dated

M~ /~7- L2~ .. /~..)

. .~. . #~ . ~~~. .