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Child or Children under SiXteen Years of Age Surviving.

I!Iiir This paper MUST be sworn to before·the Probate Judge or Clerk of the Court. ""fiM
, ­
thm,h, has not .
.. ; that the following are the names and dates of birth of all of said soldier's
HIS BY A FORMER M.HlRIA';E.
.. ____ __
That she has not abandon.ed support of any of his children, but that they are still under her care or maintenance.s
-- --- --------------- -- - --- ---- --- ---- -- --- ---- - -- ---- --­
.... .. /'orll ........ _.... . .............1'. -------------- Lorn __________ "" _______________
(/ .;
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:
........... ...... ,'Y=:'
born........ .....1/..............................
born ....... , 18......
... ............... .•. .... .... born ....... .......... ... .................. ... ........... 18
Th".fl<' ...... P""'""',,"',, ;0' "'""" h" zf!t QdcJz£L.L/.
... "",.•"'" ,", ......... ....
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(,..
their successors or representatives, her true and lawful attorneyS to prosecute her claim and recei ve a fee of Ten Dollars. Thnt her post office
.
.......................
of. _ .... .......... .
.• State of...
... .... "
..
\....... -)
'4..... ... /.. ..
.. 11: j£/lrt'i4:!
'Sit(n .. of C\';).';m:\nt
....JJ.l........ ...:;lt..
Two witness#3 who can "rite:, s.ign hete.
SEE OTHER SIDE.
"

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&T. f\uGulir'Ni,s @HURCH:·
.
REV. J. L. BRASSART.
PERRY COUNTY.
Q
REV. J. L. BRASSART.
PERRY COUNTY.
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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
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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
COUNTY OF______________ ______•_______________ _
On this______?___________ _ _ _______________, A. D. 1930. before me, the undersigned, personall • appeared
_ __, aged ____________ years, a resident of ______ ' _____________ ,
.. -----------, State of who makes the following
application for, and claim i eby made for, fro?e accrued pension for expenses paid (or obligation incurred) in the
las¥,ckness and burial oL _ _______ , who was a pensioner of the United
No. __ ,and who DIED ____
and was buned at .. -- - - -
That the answers to estions propounded below are- full, and truthful to the best of my knowledge, information, and
belief, and that no evidence necessary to a all .,ainst the withheld.
1. Wbat was the full name of the deceased pensIOner? _ __ _______________________
2. In what capacity was decedent pensJoned? (As soldier or sailor, or as a widow, minor child, dependent relative, etc.)

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? ____ uu______ u_u_uun___ n __ n""_______ nn_n_________ nn__ uu___ un__ u __ un_____'u_n_____ u ____ n __ u_uu
(c) If married, did his wife survive him? (Answer yes or no.) ________ m_u m ______ m_unun n ___ n __ __ __ m ____ __ m _________ n
n ______ (d) If so, is she still living? (Answer yes or nO.) ______________________ "=='___________________________________________________________________ _
(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-==__ mmm___ nu__ m_m__ m_mmn_______________________ ___
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_________ u _____ u ____ m _______ mmu__________ _ m mmn________ u m _______ 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 the 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 _____
21
-----_. --- --------- ---- -----.----. --._., --'" -._-------------------_..--------. -----------_....-----..---- -------.---..-_..-----------..__._....-_.-----­
14. Di1 tho doo..... 1M.. mon,y, ..
15. If of
y
_- _n,noh P'OPorl ___
16. What was e assessed value (last assessment) of the real estate?___ __ ¥.:-¥.:l2 ,
17. HO_W__ _____
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.) •__..•.•._.._•. __••____ _____________ •__•_________________________..__ •_________•______•. _. ________. ________•____
"'bat was the cause of pensioner's death?_____________ __ _ _ _____ . ________ .. _. ______________________ . ____________ . ________ •.
22. When did the pensioner's last sickness begin?_.______ ._._... ___ _m - .--...
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_/_.__ ..--.--.-...
24.
of
--------------------- ------- ---------- ------------ ._-----------------­
25.
State the nam.es of the persons by whom the pensioner was nursed during the last sickness.•._•._. __.•..••_._.... _._. _______.•_._. __________•____ ..

26. Where did the pensioner live during last . 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 & pensioner's
last sickness and burial by any State, county, or municipal corporation? (Answer yes or no.) __ .._-::::. ___ __
The following is a complete statement of aU the expenses of the last sickness and burial of said 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.
STATE WHETHER
NAMES :t\ATURE OF EXPENSES AMOU:t\T
PAID OR UNP.'I.lD
...---.-..----.. ...---.-.._=-.. _...._.2_.5._'__..!!.P

..-.-- . ______ . ._......... Underta.ker._•••.•_.___••_._••••••.•• •••••• ...._._I_..2.l.Q.__ ...__.
Livery____•••____.•___••_••.•_•.••_ .. __•••• _•••_••••__.•_ •.. ___ ._1.. _......__....___,._
___. _ _______________________ ________________ .•__ ________•__•___•___•__ . __ . ___. __ . __•______. ___________ .. _ ____ __ ___ _____ Cemetery____________________________ ... I .. ________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
= ......--..... --- -- ------ ---- ------ ----- --- -- -- -- --- ----

",'. --- --- --------- ---- -------- ---- ------,
/
2. Wh"

did th' p",ion" di,L............. .. . ...... L.... ,.. ....... L..? .... .....:...
3. .• . . .....::.....

4. Our means of knowledge of the above statements made by us ure: We kr:ew \!i1r:eased pensioner for__3(1.__ycars and____/f'-O__

____________________________________ D. Subscribed and sworn to befte me, thiL____-6.._____________ day oC___________ _ _ _ A. 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___ ___
Give name of any other physician who attended the pensioner in last sickness____
..'".t':.'::;;;""t.
-a2- ------- --------- ____Y7k___
Attending Physician•
. __________________________________________________ . 19 _____
A.ttending Physician. 6-1672
!IIi.·
~ .. ----­... ------------.-----.----=:=---=.---------..-­..-
----------------------------------
:MEDICAL DESCRIPTI V
Ward ...... Gener"ft,'Pi;al ___
..Age . ......... ,Rank . /MM.k , 0Ij:4£'1. Regiment •.......
. Lor 11 . d: - . J If ... /L4d!.. ............................._.................
Dlse se or Injury, 1.1:.. ;;!...... Return to duty, cured, .It{..CiA..(2,:I.Y..tfh....Lt[/;!: ...
Result,....................................................................................................... Ip, l h "­
INomoo' .............1omOM.] DATE OF j
M J./?- /I/ lTransfer to anoiller Hospital, ···"·.·· .. ,.. ··.·H·.. i I 1­
....................... Lk!.......z:r. ...... .................
NOTE.-Whcn6 is :t'r::Z:6 G:k:Piial. the entries on ...AlI important
cOllelition will be noted on it, (in ink,) from tiIne to tilLe, by the in cha.rge of ,:'e ·Ward. When the patient has been wounded, the d;lte and chamCler
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 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, furlough, or death of the patient, it will, with the treatment and result, carefully noted, be transmitted directly to th6
Surgeon General.
I DIET. RE)'IARKS AS TO OF PATIENT, &c. DATE.
I
/t?Y-t
OASUALTY SHEET.
......
Rewk. Company I
,Regiment,
Arm.. State, ............. ... _............____...
Place of casualty, .. u ... _u._ .•... h __ h __ .h
••••••••••••••••••••••••••••••• h ••••••••••••• : •••••••••••••••••••;;;:;•••••••••••••••••••••••••••••••••••••••
Nature of casualty, .._......... ... h •• h.h•• U •••••• m
fROM WHAT SOURCE THIS INFORMATION WAS OBTAINED
. RCp01·tOj' ICillerl. -ff'uunrirrl, (1 nd .llfissilJ,Q of 'lie 21'/
j1 Brignde,/. Division. .... Corps, dated u ••
...
... .... ... ....
('ld,