&.

;
•Tt«/
E l M B U R S E M E P I T
A.CT OF JULY14, 1862. . ;
^

^
-

(
/f<~*
'jOMJ^r^
-ej ££*
<
'
j/
% (.}^y>y/
~~T // -
''-^flJMWWwiiinijM^^ ^^(^^"SfsWfWtffilWNB^^ tMWWMjiftW11 .fHte^HsWt^KW^^^^atWeiWiWi »niU*™»»m3»M«8!^!B^^ W«<« - ^'«ntt»tft«i^W^B^»«i^
< ^
N
T
o
J
(
.
p

v
~
.

v
A
*
.
£
C

j
^
i
K
Q
>

S
^
r

I
j
^
A

£

§

/

t
:
|
^
>
,
s
?

^
:
"
v
!

;
o
^
A

!?
<
&
C
^

4

-
'
^
5
-
Declaration for the Increase of an Invalid Penfeionl
TAKE NOTICE.— If this declaration is executed before a . Justice of the Peace or a Notary Public, the certificate of tli«
OLEKK OF THE COTJBT, is to the official character and genuineness of the signature of such officer must he attached.
Xeglect to comply with this requirement will cause trouble and DELAY.
State of .t 00.
ON r..A. D. one thousand eight hundred and eighty
•=^L within and for the County and State
-- County nt..;.,-.-<S7
United States, enrol)«<1 at, thn
dollars per month, Certifleata " * *
.years, a resident
.......State of
who, being duly sworn according to law, declares that he Is a pensioner of the
________ Pension Agency at the rate of J
, by reason of disability frrnn ^-
(Here name the disability for which pension wwgranttd.)
Incurred in the
(illUtary or S^T
.service of the United States, while serving as a..
(Here elate rank, company^cffld regiment, II iu Jhe wrmvj, ve»»e)
if in the Navy.) //
t/
That he believes himself to be entitled to an Increase of pension on account ot-
. H ott account of increase in the disability for (Here state the reasons tor
^
o^--^-^
foryifmich' not pensioned, the location of (the wound or injury, the name of the disease* and tlxe time, place
p
If on account of
Jfi"circuinstanc3' of its origin, and the names of ospitalswUere treated in the se u y stated he dates of treatmeni
should be Riven an nearly aa possible.)
M i nt lie hereby fippoints, with f ul l power of substitution and revocation
-fa . , of „.
liis true and lawful attorney , to prosecute his claim.
His Post Office address is
r c<~-^7-&£-<^? t-^?^^:>?&<s'
>*~
Two witnesses who <-an write sign here.l
—7^-
Also personally appeared K .rr.rr.TrT l^,,...«...,/^.../.!?±X™-/ '.residing at .../.f..
and <rrT..4<fe<?. .^...'^^^...^.."..^..^ residing at
...persons whom I certif y to he respectable and entitled to credit, and who
$2 J ~ J/ /] J*/ *"*
being by me duly sworn, say that they were present and saw \l.. .w-^^sdtf.-.fe^dk .j/d/.. ..fr^^fcfe^T!^..!4f7r?^Vr-
, , the claimant IJ J J TI liirc H B H M (make his mark) to the f oregoing
declaration ; that, they have every reason to believe f rom the appearance of said claimant and their acquaintance with him that
he is the identical person he represents himself to be; and that they have no interest in the prosecution of this claim.
[if AJ f lants sign by mark, two persons who can write si^n hero,] [Signature of Amanis.J
Sworn to and subscribed bef ore me this ±£ day of .^.....^...^r^T^/f^'*^'. A. D.:
and I hereby certif y that the contents of the above declaration, (f ee., were f ul l y made known and explained to the
applicant and witnesses bef ore swearing, incl uding the words.... ..,„
i— i . erased and the words
rr....added ; and I have no interest, direct or indirect, in the
prosecution of this claim.
[L. S.]
I, : .^.... , Clerk of the Q#unty Court in and f or af oresaid County
and State, do certif y that , Esq.,who has signed his name to the
f oregoing declaration and af f idavit was at the time of so doing..... in and
f or said Co'unty and State, duly commissioned and sworn; that all his of f icial acts are entitled to f ull f aith and credit, and
chat M s signature thereunto is genuine.
Witness my hand and seal of of f ice, this-. day of , 188 .
[L. S.] Clerk of the...
NOTE.— This should be sworn to bef ore a CLERK OF COURT, NOTARY PUB LIC, or J USTICE OF TH E PEACE.
If bef ore a J USTIpEor NOTARY, then CLERK OF COUNTY COURTmust add his certif icate of character bereon, and
not on a separate slip ol paper.
R
H
H
O
\
Acts of July 14,1862, and March 3,1873.
Disability,
County,.-.
(6840—50 M )
_ _
On this ...._ S £ * G ..„ .day of
late of Co.—^SL —of the // Regiment of-
for an Invalid Pension.
STATE — "1A " f
County of
A. D. one thousand eight hu ndred and sixty-..«^n^^^L_.?!?i^-l personally appeaSmf'before me, Clerk of the
being a Court of Record within and for the County and State aforesaid, and by
law duly authorized to administe^ oaths for general purposes, and having custody of the^ of f icial seal of said Cou rt,
' y e a r s , a resident o f
County of -<3rr?^OAf e^=f e? in the State of
w ho , being duly sworn according to law, declares that he is
who enlisted in the service of the United States at '*3Lf a-_ < ^ J s S ^ t / i s ± £ > _ .on
day o f _. _._gp?^^<^u«-4*/ 186/ , as a x.'^ jf J C.^ f M:-'. ' .' _-' in the Company commanded by
.^^k^S^.'^.Aife^^^ , kiiownj^Company^^/jL^—^in Jhe._^,_^^^^r
I \s /ft / £~ '
Ro f f i mc u ' t of,(JyW../Sxi4xfc^A
-. . . _ ., . , „ , , , ., .- - _, _ / s ^ -Cr*es ^ -*-~*~< '
-*-- volu nteers, in the war for the suppression of the Rebellion in
certain States of the Un i o n , and f ar the mai n t en an ce of the Federal Go vernment, and was honorably discharged on the
. . . . &2/ j3. ...........day of ________ V: •^ ^ ^ ^ ^ ^ ^ ^ ^ - .....in the year 186^, as appears on the Muster Roll of said Company,
and also on the Surgeon' s certif icate of disability, ' which is filed in the Pension Bureau at Washingto n, and is to be deemed
and treated as part hereo f , and that ho.was discharged at ______*> £ 3> < z ~- - - ,S *£ ~. S ? > r± s ± ? 9 - ....._^ _? 7? L^ v ____ ......________ by reason of
' That while in the
,
said service, and in the line of his du ty, he received the following wounds or disability, to -wit: OnAthe
day of , -O-I^L __ .., A.D. ** ' & *- *i sj k . < S tT T t< *i t - < 2^x*j rrs- v^
j t ~ / " A— r ,/ ~ ' / /
J?f^- ^^ t7
^^y-
*3& lJi & Uj L^- ^^- & tts& J& ^^ & CsXtS >~M^e^. - - £?^L< f>~*^*(^
I A t , •
If i i n ' ,t
.^ jAFf ± ~!? ^ --< »b? Cl< 4< 3^ 1s Zt o^ r&
, - - . - , -
t^r^\~£< _^>i A*4*~£i s/ j (. s£L^Gr?~*t~^ • *Vf- ,^f4H< * — ? — t^f^- Y^vsociX^/1— Xfer^zx^l^*^a«v £i ~~f*+J I A — Vi<£- ^/
This applicant'stsEennMhisT^stlJffice iaof dress is ^ £ §^ ^ £ ^ 7 ^ __Uo u n t yo f
X T" f ^^ A^zJ^S^i// ^
State of _______ ^O?TM<-^o ^^^-t^T.^_______ ; and this applicant solemnly, swears that he has at all times bo rne and will bear
tru e f ai t h, allegiance, and loyalty to the Constitution and Government of the United States, against all enemies, whether
domestic or f oreign. /•,. .a
And I , the said applicant, do hereby constitute and make H EQ U EM B O U R G fttetL, of St. Louis, Missouri,
my Attorneys in f act and irrevocably, for me, and in my name, to prosecute my said claini and to receive and receipt for the
Certif icate of Pension which may be allowed me therefor ; and generally to do all and singular such acts and things as may
be necessary in that behalf.
WI TN BS
THE'FOREGOIN G DECLARATI ON AN D POWER OF ATTORN EY OF-
applicant for an Invalid Pension, was sworn to, acknowledged, and subscribed b
and also at the same time and place, personally ^appeared before me,
me, ^he>lay and y^ar first above wr itten,
-
A
P
P
L
I
C
A
T
I
O
N

O
F
-
H
E
Q
U
E
M
B
O
U
B
,
G

&

M
i
'-
D
O
W
B
L
L
,
S
T
.

L
O
U
I
S
,

M
O
.
^
^
S
iJ
^
^
a

i
% Certificate No ,
r, ' 3 / 7 '
|f Pensioner .^^L^^^^L^.
'•j ClasaJIUDQML^E
|S,, •' (
i, Date of Death
fV Claimant:
8-E472
L
* l - ' • • - • - - ' - • « • • * ' . ' . ' .
IN REPLY REFER TO
Widow Dlv RS. 3~1865
I.C.347479
Hannah^Sulliyai£EpARTMENT QF THE
ratriclc Sullivan
C 11 Mo. Inf. B U REAU OF PENSI ONS
WASHI NG TON Deo.14,1930.
Mr.Robert S.Sullivan
3768 IcCausland Ave.
St.Louis,Mo.
Sir;
Relative to your claim for reimbureement in the
above-cited case,you are advised that the enclosed
certi fi cate should be signed by Doctors R.S.Hill and
S.H.Reynolds and Helen Sullivan and returned to
this Bureau.
Very respectfully,
« » # Commissioner.
JG B WDC.
r
» § *
femuift.
pIP; '*^^^'^^-Mf^
in
^ Halte
Very
» P.Bill
to
W 150,
MEMORANDUM
Maplewood,
S. H. REYNOLDS, B. S., M. D.
191UD
For Professional Services To.
Received Payment,
BILLS RENDERED MONTHLY
FormP-26
-RICHMOND HEIGHTS
ST. LOUIS CO., MO..J
HOURS:
To 9 A. M. 12-2 and 6-8 P. M,
KINLOCH, MARSHALL 268-R
BELL, BENTON 409-L
To Balance ,
To Professional Services
- # M *
Q&*& *•
QJ**Z V
**& I
&,?$* f
<**"£ |
<M ?' fc V .
«^*r • *
oSj? ' *
astv " : >
<LfZ "
,_. Jt
^^M Ij
If
^SW "
att ^
it
*%*••
<7ifT ;,
* e/
-~*1
* II
' • O/
»4> \ \ \J
' , ' , t
<3 *7 f*g >
, . o g
" ^"2
/' -9^
., p-C
» /»^& i
h g7?
" "^
""' » ^ '
ri«^ci[^Vv8!t'tiftw»?w^^»*roLwi«J'*itoM»«^ f^«vnV*~<r
3—1O81
PENSIONER DROPPED
DEPARTMENT OF THE INTERIOR
BUREAU OF PENSIONS
\>
o
The Commissioner of Pensions.
Hi-r: • ;,.
/ 'litive I lie, I vOi'ior to report that the, it,a,n/ .r> , oj'
Ui-!' aJHrvc-dc-xcri [ > < > ,< I , pt'ii> ;-ii,oit,Kr who wan l/ int
na,!,l a,l & 3$,lo (2^4• V. / 9^
« ./- r / '
A /
'M M this (I ng lH'fyi/ lropw',il lff'oni,ltiw jru l-f- I K:-
Mm*-.
S T L O U I S t] 0
2 4 7 • '; 7 D M A Y
3 5 00 c i . i v ; ; :;r,:
f
' W I D
Very respectfu lly,
'< &> &&sUa> &
3-81O
Claimant
Street and No. _ b
Rate, $.:^L<?-
Last illness commenced
Last paid t o . - f
f* • •
Date of death ..Afe<^i-*,..<3a^./i.y.-A;.«.... ^Accrued pension $i.-K:^,_ _ _ _ _ /:
AM O U NT S CLAI M E D.
Physicians' b ills _ - - - - -
M edicine _ -- v -
Board
Nursing and care ~ ~ _ - - - -
Rent -
Living expenses for pensioner
U ndertaker's b ill - ~ .
Liv erv
OTHE R E XPE NSE S.
-~^y~^
T O T ALS ./ _ ....
/
$
CHARGE S
APPRO VE D.
f7
$ SO
'**-
-? i-S-
^^3
-*-*
^> ~< >
DE DU CT I O NS.
State aid
Assets
I nsurance
T O T AL
$
SU M M ARY .
Charges approved
Deductions
Amount approved
X"'

^ ^ ^
-*-*
f
Approved for
t
Examiner, ]{/ Reviewer.
Courtney, C. Alclrlch,
Sec. & Trens.
Laura A. Parker,
President.
Orrln B. Laug,
Vice President.
WEBSTER GROVES
Bell, Webster 205
MAPLEWOOIJ
Bell, Benton.31
Casket_
Box
Metallic
Grave Vault
Burial Bobe Underwear and Sundries
Engraving Plate.
Washing and Dressing
Embalming- and Preparing Body
Candalabra and Candles
Flower Auto -
Newspaper Notices _
• Deliveries
Flowers for Door
Chairs
Cremation Charges
BemovaJ Charges _
P 4. ">* ->
Outlay for L«*-TMS Grave o-*->. ./rr»-<PTEvergreeiOJlning'
F r • "• ' V
Bearers' Gloves
Hearse
~* • • & .
funeral ffljrn|sWng:s
Personal Services
^^/ULMbtso
* & ^^QA£^%
~
D° —
£> 0
2 -
s^^
3—1129
DEPARTMENT OF THE INTERIOR:
BUREAU OF PENSIONS I
WASHINGTON
. •
Under an act of Congress approved "by the President May "
"
from that date is increased to $30 per month
ATTACHED TO YOUR PENSION CERTIFICATE. ,/-^^
"

THIS SpIP SH
your pension
BE SECUEELY
Commissioner of Pensions. Secretary of the Interior.
MF . 14
; ' . (808)
The pension accruing f rom, date of last payment to date .t
pensioner's death in this case ijs 737777: and no
sum is available for reimbursement.
I hereby certif y that I hold
•responsible for the payment of any portion of the accrued pension
to which I may be entitled for services rendered, supplies f ur-
niched, or money expended during the last sickness and burial of
< • » ' v
--• S^rrrrrrrt^.^r-^cv ^^TC^rrrrrt late a pensioner by certificate
! 1 '
-£j£3 (* /-~ ,- "
numb er..-^.^^../^. $ •_ _ .
(This. need not. be sworn, to. )
S T . A U G U S T I N E ' S C H U R C H ,
2568': 1EBEKT STREET,
R e v , H . H U KE S T E I N ,
/
ff
( A t t o r n e y ,
kSt ..
(3—128.)
WIDOWS PENSION.
County ^^_!A^-^*^&^_._., State
Commencing .-
*-—. per month,
and two dollars a month additional for each child, as follows:
Born, , 18
Sixteen,. , 18
Bom, _ . , 18
Sixteen, , ,18
( Born, , 18
(Sixteen, '. , 18
Born, 8
Sixteen, _ , 18
Bom, ..^?7C;.^. , 18X5. )
Sixteen,
Born,
Sixteen, _ ' tK.i. ,
( Born, _ ., 18
|Sixteen, , 18
( Born, ,18
( Sixteen, , 18
Payments on all former certificates covering any portion of same time to be deducted.
All pension to terminate , 18 , date of
18
18
18
18
, 18/f.
18
18
RECOGNIZED A.TTORNBY:
P . O . . - - - - Articles
A I5 PROVALS:
( . '
-, origin of Approved for^T??^^^sf8^*a^; death resulted f< Approved for^

^
kh has been legally accepted,
edical Ecviewer.
Medical Jiejeree.
T
IMPORTANT DATES:
Enlisted ^t^^-C-:../ } \%&/. || Invalid application filed....^**^^.-/^! , 18//.
Mustered _....>^*3^u< < -:.--^.6 , 18^7. Invalid last paid to ff^^^^:. .., 18
< 2 f
Former marriage of soldier-.-'^^^r: Discharged
Died
Declaration filed .
Death of former wife , 18
' /
Claimant's marriage to soldier.^i
i

•<
*
(3-562.)
.AOOIR/CJIEID
UNDER SECTION 4718, B. S.
Pensioner, .... . . - ^ r z &^ c , _ _ _ _ _ _ _ _ _ Certificate No, .
- * ,7 «.
o/ death,
^^
Claimant, -
V
SUMMARY OF EVIDENCE.
Relationship of claimant to pensioner is shown by
and date of the pensioner's death are shown by - t
A PPRO V E D
Claimant,
P. 0.,
County,
State,
Attorney,
Rate, <
INVALID PENSION.
Rank,
Company,
•/ y
Regiment, 7 ft
per month, commencing
Fee,$
Disabled by
Submitted
Approved for
Discharged
Original application filed
Increase application filed
Pensioned
•f°r $M^^
Claims
Reviewer.
Approved for
,18 ,
V
, Examiner.
Med. Referee.
Certificate surrendered
Last paid at $ , to
(3-145.)
• * > •
INVALID PENSION.
Claimant,.
p . o.,.-Jt'
,,^r^%
State, _.
/Sank, (s
Comp any,
Regiment,
_/• * "'
'
Kate, p er month, commencing
Submitted ftr (^L^L^L-.jLP.i. , 18
^ _
Ap p roved for ..£.1:^?^^^
* //
'..r....t 18<?*f. Last p aid to ..... -., at
Original declaration filed
/ /^
/ed from .... $:.&&&%'--.£$-•--•, 18W, Arrears allowed
Declaratip n filed ....j£y..Z.£L~Y—t. ..., 18
//
f ,
(7280—75,000.)
'AR Q!F THE REBELLION.
i • :. C f 0 '
INVALID PENSION—ORIGINAL.
Eank, . . r^
Regi ment, .<^...o....5:
1 SERVICE.
,18 , i n
Materi al evi dence fi led si nce July 8, 1870.
Di scharged (taken from
Eate of pensi on, $ .permonth, from
Declarati on fi led... , allegi ng di cdbi li ty
THE ADJUTANT GENERAL REPORTS—
Enli sted,.. ,18 ^Mustered,...
Transferred to V. R. 0.,.. , 18 ; cause,..
Di scharged,
RoU for
j coveri ng date of alleged di sabi li ty, says: ..f?^~?
, 18
THE SURGEON GENERAL REPORTS—
Treatment in
The certificate of disability for discharge given by Surgeon, says
,18<££.
PAROL EVIDENCE AS TO ORIGIN OF DISABILITY.
Testimony of commissioned officer,
(filed
Testimony of Comrade
(filed
Ex. Snrg.
Ex. Surg.
MEDICAL EXAMINATIONS.
Finds..
Finds..
\\ Ex. Surg. Finds
Dis.
Dis.
Dis.
,tS.
Cert !icat« No. Acts of January 25 and March 4,1879.
BRIEF FOR ARREARS OF I NV AL I D PENSION.
Rank,^ ' £x/L=r , Company
VL&*
'. 0. addre'ss, / , County lZ/£
Discharged from service ^—rr^.^^LL^.^^^ / . ( / _ _ . _ , 18
Subsequent service from , 18 , to ... 18 .
'^ff
Was first pensioned from.... / .Z^K-..^... ./„</ , 18/ ^at the rate of $_ _ L.£L_ rper month.
Dai:,,
Approved for issue:
• / > x
Arrears of pension due at the rate of $ ^J per month from ^^^^^^LL^L^ L,JL, 180y?
Examiner.
i
(a—111.)
-i-
1 Attention is invited to the. outlines of the huma n skeleton and figure upon the back of this
certificate, and they should be used whenever it is possible to indicate precisely the location of a disease or
injury, the entrance and exit of a missile, an amputation, etc.
The absence of a member from a session of a board and the reason therefor, if known, and the name
of the absence, must be indorsed upon each certificate.
Insert eharacterf
and number of
claim.
Name a iu.l rank
of cla ima nt' .
Q^panv^.^.^^^..^^....^^-
C luinmiit' a poa t y
^ 3 address. ^r-- - ^f^y ' ( Da te of exa mina tion. )
r 6%
We hereby certify that in compliance with the requirements of the law* we have carefully examined
this applioMfGv'ho,states that he jsjjjufferine frMB-^he follcjwirjg disabjjigj, incurred in the servics, viz:
Cause of d ia a -
bility.
e receives a pension of——_ —= - .^r~/?-- _ dollars per month.
if not, erase the ^y\* 4& >y /~^jf^'~7
whole line. Pulse rate per minute, .Z-<£L_; respiration,—<^2^i—; temperature,.../^??-—~j height,
feet—y£. inches; weight,— f—^^.y....pounds; age,— -*£.x2—years.
the following sja^ement,u,pon which he bases his claim
^^.^/^^^i^
examination we find the following obj
'erjff^r^^T^ ^sz~
^^Z/^/3*£/^
—...»_ SBT,_ _ ^C_ U _ _ _ _ -_ j < . '
Ki^iis, uit i uuii- f ^ s i "^jy * ~.^ ~~ f s si
S'!?£^^-^^™^^^^
'wnU!11'6 c^^^/^^^-*&&'{»>£*-._ S^-^^/^^^^—t ^~£^<^&J^<'^
^
- ,
"
C*TH>^
It must be borne yr..fc y1
in mind tha t *^~
iho duty of the
Sui'geon is to
portionato de-
Ac. , through
•yard to dollars
and ccnte, and , -->v>£" s
to make such a/^Z S^T^C-
full particular
description as
will afford to-
this O ffice the
ion a ntl action
ta lftting-
Kate for ea e/t
au^of dUa-
the word not
e li o u 1 d b e
erased uud the
reason for the
erasure given.
From the existing condition and the history of this claimant, as stated by himself, it is, in our judg-
ment, probable that the disability was incurred in the service as he claims, and tha^it
sD &? £r /
not been prolonged or aggravated byvicious habits. He is, in our opinion, en tided to a
for thejjisabilife^aused J?/r^:^^ that caused
* See tlie back.
_ JHere state -whether for .ojiginaj, increase, jestoiatioii, or renewa ljO r for a re-rating;.
N. B.- -Always forward a certificate of examination whether a disability is found to exist or not.
(6127—100,000.)
( a —i n. ) r
f
• Attention is invited to the. outlines of the human skeleton and figur e upon the back of this
cer tificate, and they should be used whenever it is possible to indicate pr ecisely the location of a disease or
injur y, the entr ance and exit of a missile, an amputation, etc.
The absence of a member fr om a session of a boar d and the r eason ther efor , if known, and the name
of the absentee, must be indor sed upon each cer tificate.
Inser t char acter !
and number of
chiim.
2Jame and r ank
of cla i ma nt.
Cl ui n i i ui t ' s
cilice addr ess.
-— Pension Claim No..
( Da te of exami nati on. )
We her eby cer tify that in compliance wi th the r equir ements of the law* we have car efully exami ned
this applic£ur fO?hor states that h^ js__suffer ing fr om- ^he following disabjjjg?, incur r ed in the ser vics, vi z:
Cause of ( Ha a -
bllity.
if not, er ase the
whole li ne.
r eceives a pension of—_«^ _?~i5l. dollar s per month.
Pulse r ate per minute, Jf..^...-, r espir ation,—f^.^i...; temper atur e,.- ^??—- —) height, -.y.
....^f-. inches; weight,— £0^^?....pounds; a.ge,—-^/&2—year s. /j f^~^y
kesthe following s>^ement,upcm which he bases his claim for ^y&r?S^&^ ^^^^^
4 s
n examination we fina thp following obeowft- eor iBiJious: .
id dollars
and ccnfa, and
to make tmcli a
full par ti cular
descr i pti on
_ _ _
Bate for each
c»«o of <!«,
"vlckm"Miit?
the wor d no(
s h o u 1 '.1 b a
er ased and the
r eason for tho
er asur e given.
Fr om the existing condition and the histor y of this claimant, as stated by himself, it is, in our judg-
ment, pr obable that the disability was incur r ed in the ser vice as he claims, and that^i ti as
not been pr olonged or aggr avated by vlpipus habits. He is, in our opinion, entijjed to a_t<2 .^fc?--'?
r ating for the disability^aused M- ^—^.1'^ that'caused
a seer
"See the back.
r,\e state whetherfororiginal, inciease, jestoration, orrenewal, orfora re-rating.
N. B.- - Always for war d a cer tificate of examination whether a disability is found to exist or not.
(6127—100,000.)
.
SingL
will er
foot of ti
1FICATE
this blank, changing "we" to tead "I," and "our" to read "my.rr They
"Sec'y," "Treas.," and "Board" where the words appear, and sign at the
'.on the back of the same.
Applicant
State, .: ^.,U.
V - c '
P . S. W rite } ou, P cSi-fffiee adcjress plainly and in full.
P ROV IDED FURTHER, -That all examinations shall be thorough and searching, and the certificate con-
tain a full description of the physical condition of the claimant at the time, which shall include all the
physical and rational signs and a statement of all the structural changes. [Extract from Section 4, Act of
Congress approved July $15, '
(3-
E X A M I N I N G SURG E ON ' S CE RTI FI CA TE
I N T H E C A S E O F AN A P P L I C A N T F O R I N C R E A S E O F PEN SION .
G SDBGEON'S AJP»BKSS
t office,....
"/
(ir^^rfy^fr...^^^^/^
*^..&r£4i& ;
-
13g{ fc
* sa?
lilt
S P^O
^*»
Jttaaina /iom me condition ana fMtoi-u tx f we etaitnantj it it) .jfct^y.. opinion
C M inoetHeaf on tfne deivcce C M oiacfneiZj < & nc& tnat it ii net aaaictvafeef oi
• f ff
vicious navitA. /?
L22y
/{/net tne cWavfaitM C M cweve ctedett& eat,.to. qntittA mimto a ..JTK^^f-'
' s f " a ~£f~irJ~/'^ ?
& s £"* * '!/ G E ji— 's
^^^>C ^%£ /^5^E x amining Surgeon.
The Surgeon will forward his report of examination direct to the Pension Office wlwther the pensioner is thought to be
entitled to increase or not.
•*»>r
a<<
(3-Hfi;)
E XAMI NI NG SURGEON'S CERTIFICATE
IN TH E C A S E O F A N A P P L I C A N T FO R I N C R E A S E O F P ENS ION,
2
&m tine conation ana /Mto>iu
/
incctiAea in tme deiw'ce ad ct
e ctaitnant, ( X ia .j
'
aj ana tnat M M not a oi,
The Surgeon will forward his report of examination direct to the Pension Office
entitled to increase or not.
Examining Surgeon,
pensioner is thought lo be
• 3 8
3l l f i : )
E X A M I N I N G S U R G E O N ' S CE R TI FI CA TE
I N T H E C A S E O F A N A P P L I C A N T F O R I N C R E A S E O F P E N S IO N ,
E X A M I N I N G SUR«BON 'S>j)DBE SS:
Post of f i c e ,
County, -"/
State ,
Company,
Re gi me nt,
State ,
Date of e xami nati on, _______
f r < _ , , '188
Thatthepresent
r at ing is un-
justly low, or
that there has
b e e n a ct ua l
increase of the
disability.
^Par ti c ular de -
sc r i pti on.
ing for one
two reasons—
that the pres-
ent r at ing is
unjustly low,or
that the disa-
bility has real-
ly inc
In eit!
the reasons for
changing the
' present rating
ishouldbeclear-
afullstatement
of the physical
and rational
signs.
•^f f ^-^ e ^ < jf ^^-^^:^-^^z, ^t.
7^^
^.p^.^^^^^k^^.^^^.-v^^....^^.^^^-^^^.^^^-
^fer-< ?t£-:z££?&&< l£*!6£2 &£:--x:;.-..jtz>£^:.
s
S a f e g
-^.i
••a ?*
E H -«
«
f ac /ai na /i om me c onc uti om ana /Mf oi u of me
V CM i nowki e at on tne de i f i e s M c tai 'me a, a

vi c i att;) navi f a.
c m a&ove
i t M not aaai avaf oa
The Surgeon will forward his report of examination direct to the Pension Office
entitled to increase or not.
Exami ni ng Sur ge on.
pensioner is thought to be
5
'°SURGEON'S CERTIFICATE
D«fe of Examination i
/? ^
Examining Surgeon,
Post Office, -,-
County,
State, ; _ . . — . _ _ . .
P, S . — W r ite your Post O ffice ad d r ess p l ai n and in ful l ,
|tUi JM.) ELECTRO'S.
3—O44
APPLICATION FOR REIMBURSEMENT.
(This application, when properly executed before some officer having authority to administer oaths for generalpurposes, should be
forwarded, together with the pension certificate and itemized bills of all expenses, to the Commissioner of Pensions, Washington, D. 0.)
STATE OF_ _ _ _ _ _ _ _ rn^ _ ^ l^ il_ » _ _ j , _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
* - f • «
COUNTY OF_ _ _ _ .„!/_ _ _ _ _ _ _ _ _ _ _ /IL_ _ _ ;- - £. _ _ _ ''—_ „-:. ...... _ _ _ _ _
On this _ ..... -t^t-wZ-/'.l_ ......... _ _ _ day of .._ ,..,:-<-'. — LJ..i.^.- .i^l.t.- '..f . — , A. D. one thousand nine hundred and.^lj ,4^**M-3Zv»
personally appeared before me, a"l.i^j Lt_ _ _ /,j ._ j l.,_ _ _ _ s:.ft_ .j ^_ ,.,,,_ _ \.,.._ _ _ _ _ _ _ _ _ _ ..... ..within and for the County and State aforesaid,
^l—Z—.ZLT-'. !.....i^r^-i-^i , aged ^}3..^2...^. years, a resident of
, County of _ X_ -'-^..y£^--^~~-~-^~-ij f-' » State of
, who, being duly sworn according to law, makes the following declaration in order
to obtain reimbursement from the aacrued-j ension for expenses paid (or obligation incurred) in the last sickness and burial of
jt. l/l_ _ lX^fci^i:t« <££?^^----%J^^ who was a pensioner of the United States by
certificate No. j oZ-^.->fcl-j (!.^~-/~----i. °n Account of the service of....—l—^^f /jK^A- - - - - - - ^ 1 u.^,—'-."j f.-r.^r.A,
-i—» ** f , f - - .^ f , . _ „ ^ - JHame otj »ldier oM^lw.Vr /» ,, >
k..^i^_ ^4^......^^.^^^.^.A,-^.-.-^f^^^^-Z
wcg^by company ami^egpj &ntyqti^ if 4n the Army, or by the words U. S. Nayy, ij j yn the iNftvy.)
That pension was last paid t^.AM4f ^^A.sM^^^£f ^£^i- .- ^.., .481' <i£&*!~^- €f / YQ^- & >
That the answers to questions propounded below are full, complete, and truthful to the best of my knowledge, information,
and belief, and that no evidence necessary to a proper adj ustment of all claims against the accrued pension is suppressed or
withheld.
1. What was the full name,of the deceased pensioner? ../lii
2. In what capacity was decedent pensioned? (Asinvalid soldieror sailor, or as a widow, minor child, dependent relative, etc.)
3. If decedent was pensioned as an invalid soldier or sailor— i
(a) Was ne ever married? (Answer yes or no.) ^. • ^
(6) How many times, and to whom?
(c) If married, did his wife survive him? (Answer yes or iKj .)
(d) If so, is she still living? (Answer y« j K>r no.)
(e) If not living, give full names and dates of death of all wives -
(/) Was he ever divorced? (Answer yes.or no.)
If so, is the divorced wife still living? (Answer yes or no, ) ---------------------- ....... ----- (If living, a copy of the
decree of divorce must be filed.)
If not living, give her full name and the date of her death_ _ _ _ _ . ................ . ................ '. .......... _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4, Did pensioner leave a child under 16 years of age? (Answer yes or no.)
6. Is any such child still living? (Answer yes or no.) — /
6. Were any sick or death benefits paid on pensioner's account? If so, give name of society and amount paid ~t.- ~ „. v **^
•"" ~ " " ; y
7. Was there -insurance (life, accident, or health), in {oroa,,on life of pensioner.at time,,oi death? (Answer yes or no,) ,,
8. If so, give the name of each company in which a policy was carried and the amount in which each policy was written
9. Who was the beneficiary named in each policy?
10. What was the relation of each beneficiary to the pensioner?
11. Were the premiums paid by the deceased pensioner? _
12. If not paid by the deceased pensioner, state the amount of premiums paid by each person who made payment on that
account
13. Is fcare anlsxecutojf cjj1 administrator, o:r will application be made for appointment of any person as administrator?
doner leave any money,' real estate, or personal property?
• „-
15. If so, statetW'dharac^er and value of all such property
i. What was the assessed value.j0agt.assessment) of the real estate?
17. How was the pensioner's property disposed of?
18. Did pensioner leave an uriindorsed pension check? (Answer yes or no.)
19. What was your relation to the deceased pensioner?
20. Are you married? (Answer yes or no.)
22. When did the pensioner's last sickness begin? <^li_lferl£»r^7_-__.<
' /
23. From what date did the pensioner become so ill as to require^the^jsegular and daily attendance of another person constantly
until death? .
24. Give tha name and address of each physician who attended the pensioner daring last sickn
26. Where did the pensioner live during last sickness?
27. Where did the pensioner die?
28. When did the pensioner die? jjLr<^z/-?d?,_^»Z_.
29. Where was the pensioner buried?
30. Has there been paid, or will application be made for pa^sSfeut to you or any other person, any part o'f the expenses of the
81. State below the expenses of the pensioner's last sickness and burial. Write the word none where no charge is made in
case of any itemof expense noted.
(Each charge entered below should be supported by an itemized bill of the person who rendered the service or furnished
siny supplies for which reimbursement is demanded, and should show, over his signature, by whom paid, or who is held
responsible for payment, and contain the name of the pensioner for whomthe expense was incurred or service rendered.)
STATE WHET HER PAID
O R U N PAID.
Physician .
Medicine
Nursing and care
Undertaker
Livery
Cemetery
O ther expenses and their nature
f
32. Is the above a complete list of all the expenses of the last siekness and burial of the
deceased pensioner? (Answer yes or no. ) -------!ZZ3?~^~- ------ ^)- ..... ^g . n ,-
*» -I'/ O ( - ~/MS <( * *J* *. £' *»£*-{
That my post-office addresa,is No.-^V... /. . ( £>. . &- _______ , on____ ^./J^...V..S:«4-«^a«*8l!rS!S*ri<S_ ................ _. street,'
(T"V^ r^ '
town or city of .....Jfe^r.A^J^* * s* d?..-.......... - .....----------------- , County of .
'State of.. _____
(When the claimant for reimbursement is a married woman, she is_ required to sign the application with her own full
name, not using the Christian name or the initials of her husband, and all bills should' foe ..receipted to her in herjuyn name.)
(Claimant's signature in full.)
1, , the claimant, sign "who, being duly sworn, say that they saw.yL?*^
name""*;/(or make _, : mark) to this application; that they know the claimant herein and that their answers to the
following questions are true:
1. Did pensioner (if a soldier or Bailor) leave a widow or a minor child under age of sixteen years surviving?
, « . . . , .
2. When did the pensioner die? ^ ^i._-__-- -.
3. Did pensioner leave any property? If so, state its character and value,.
4. We knew, pensioner Jj. years. W^ believe above statements to b,e tmal-because _.
Name -j ! -"__ ,. , , Name —ij i-'r^ix
P. 0. Address , . ' '" P. O. Address ._Z^..2./l^../*S^i-i-Y--f.-..*.k."fc>-.*-<
Subscribed and sworn to before me, this -^L.efeTL. day of .-i-liu.-.gfcr-.^j.j-^. i.». '—-
A. D. 19jtjSt; and I certify that the contents of the foregoing application were fully made known and explained to'the
claimant and witnesses before swearing, that I have no interest, direct or indirect, in the prosecution of this claim, and I
further certify that the reputation for credibility of the witnesses whose signatures appear above is _._ „'.
STATEMENTOFATTENDINGPHYSICIANS.
Give dapJrof the pensioner's death
!0(fve date of commencement of pensioner's last sickness './J3.
From what date^ did the pensioner require the regular and daily attendance of 'another person constantly unfctl death?
^/£*/?
*^
During what period did y$i attend the pensioner 7"s&!*!
State nature of disease from which pensioner died _•
Give name of each person who rendered aarvicoAs nurse, and who has made or will make a charge for s,uch service...
«i^
Give name of any other ghysjcian who attended the pensioner in last sickness ......_____ _• _
j Does your bill include a charge ffi all medicine furnished the pensioner during last sickness ? .C^
Has your bill been -gaid ; if so, by whom?________ jQ3£«^_.^fe-*»!tf-<x::3!**«t^
Mention any other facts within your knowledge which in your opinion would be helpful in adj usting this claimfor reimbursement:
?X3&---J£»^4*^^^J&
.7 / ? /. t
I certify that the foregoing statement is correct.
6—1572
ttending Plwsin
Attending Physician
.-., 191
MiL
' t ' 1 ' « i « M 0 H > 0
* < g * > s &aa g g eL* ^ft||s s 3"i!Si sr
o f»!§.B'S* t°B tt'&l?'8:l^w^S S ffl 1S "«•"
' • • «l' ^4l:s4fe^iw§*aa«i?s,?.:T^i
' - !
§
0
The Act March a, 1895 (28 Stat. L., 964), provides— /*
That from and after the twenty-eighth day of Sep.tember, eighteen hundred and ninety-two, the accrued pension to the
date' .of the death of any pensioner, or ofany person entitled to a pension having an application therefor pending, and whether
a certificate therefor ' shall issue prior or subsequent to the death of such person, shall, in the case of a person pensioned, or
applying for pension, on account of his disabilities or service, be paid, first, to his widow; second, if there is no widow, to his
child or children under the age of sixteen years at his death; third, in a case of a widow, to her minor Children under the age
of sixteen years at her death. Such accrued pension shall not be considered a partof the assets of the estate of such deceased
person nor be liable for the payment of the debts of said estate in any case whatsoever, but shall inure to the sole and exclusive
benefit of the widow or children. And if no widow or child survive such pensioner, and in the case of his last surviving child
who was' BUchT' minar at hjs death, and^in case of a dependent mother, father, sister, or brother, no payment whatsoever of their
^ttWrtiTO
of their last sickness and burial, if they did not leave sufficient assets to meet such expense.
The Act March 3, 1905 (33 Stat. L., 1169), provides—
* * * and no part of any accrued pension shall hereafter be used to reimburse any State, county, or municipal corpo-
ration for expenses incurred by such State, county, or municipal corporation under State law for expenses of the last sickness *
or burial of a deceased pensioner. ' ,
INSTRUCTIONS.
1. Accrued pension is not a part of the assets of the estate of a deceased pensioner, nor liable for the payment of the debts •
of such pensioner.
2. Accrued pension is not payable as reimbursement in the case of a person pensioned en account of service if a widow or
minor child under sixteen years of age survive.
„», 3. Accrued pension is not payable as reimbursement in the case of any pensioner who left sufficient assets to meet the
,*,,!***expense of last sickness and burial.
4. Application for reimbursement should be accompanied by the following evidence:
(a) Bills of all expenses of last sickness and burial. If paid by the claimant for reimbursement the bills must be
properly receipted to said claimant; but if paid in part only the creditor should state by whom paid or from what source
sucn payment was received. If unpaid, the parties to whom said bills are due should note on each bill, over their
signatures, that they hold the claimant responsible for the payment. If the bill be for medical treatment it must show
the dates of visits or treatment and the charge for each. A bill for nursing and care must show the dates between
which the services were rendered, and the rate per day or week. The bill of the undertaker must be itemized, and
show the date on which the services were rendered.
• Each bill musfcshow that the service was rendered for the pensioner on account of whom reimbursement is claimed.
All claims should be presented in the name of one person.
Bills' which are forwarded become a part of the-recordsof the Bureau of Pensions and can not be returned. Claim-
ants should therefore secure duplicates of such bills if needed by' them.-
(6) The pension certificate which was, issued in the name of the pensioner. If such certificate is not in possession of the
claimant a statement showing its whereabouts or final disposition should be made.
5. A careful compliance with these instructions will save much unnecessary delay in the settlement of the claim presented.
NOTICE.
The only sum available for payment of a claim presented on this blank is the pension unpaid at the date
of the pensioner' s death. 6—167 2
£2g^«=£3SL..-., 00:
v
. 188 0;personally appeared before me ON THIS J^.-.C:......^ day of
in the County ofi- r±Z^..-r^.- rrTTT. :.:: and State
Post Office address is ...-.C--.;....rrrrr. _ „
well known to me to be reputable and entitled to credit, and who, being duly sworn, declared in relation to aforesaid case
as follows:
. —Affiants should state how they gain a 'knowledge of the facts to which they testify.]
further declare that-&^rrTJ^!??rr5*^^^no interest in said case and <?s?:#^T&!=rr_ _ not concerned
its prosecution.
(If Affiants _ jign by mark, two wftnease
• tjw'' above-ifamed affiant , and I certify, that I read said affidavit "to said
- erased, and the words
• TV,;.- .....'j.-.-i-, added
'and acquainted---;^T^.*l*'S-'— ...with its contents before. — /tx~^_—executed the same. I further certify that I am in
nowise interested in said case, nor am l-concerned in its prosecution; and that said affiant T^^:.. — personally known
to me and that.~'?^?SrC.'r^—...s*?s-—. credible person.
I, - — Clerk of the Counw Court inland for aforesaid
and State,'1 ^certify that— , Esq,., whofcas Bignea-bia5|toe,to the
foregoing declaration and affidavit was at the time of so doing - in and
for said County and State, duly commissioned and sworn; that all his official acts are entitled to full faith and credit, and
that his signature thereunto is genuine.
Witness my hand and seal of office, this—. — day of , 188
[L. 8.] Clerk of the
NOTE.—Th'is should,,be sworn to before a CLERK OF COURT, NOTARY PUBLIC or JU3TICE OP THE PEACE.
If before a JUSTICE or NOTARY, then CLERK OF COUNTY COURT must add his certificate of character hereon, and
not on a separate slip of paper.
o
-
w
I
'.
'-
R
n

"
«

'*
V
-
'\
-
^
N
I
S
)
/£>•
/7
!f/
<^^—~
. . . i
w
rr?'
r-^-^inyvi^j TW xi
077 y^
/ -
* O M 'smo'i
6T©
l u ! E I O
,
r
' }
.S6S-PH YS'J.01&.N8 , OUT. THESE,
C e r t i f i c a t e must be 'fully a nd;a c c ur a t e l y f ille d out, or ,i t will not be r e c e ive d a nd signed,°®«
o f Deceased: ^..^...^...
Years, Mo nths,
Cross ouf t he wor ds not r e qui r e d.
Place o f Birth .
Place o f Death .ii££...**f &*..<f ...t.
Date o f Death*.
Cause o f Death..
•I CERTIFY that I attended the perso n abo ve named in.,
the disease stated, o n the date abo ve named.
last illness, who died o f
M. D.
| Place o f Burial^.....:.
Undertaker.
i OFFICE HEALTH DEPARTMENT,
St. Lo uis, Mo ., 188
I CEETIE7;:that"I have examined this Certif icate, and f ind it to acco rd with the requirements o f the City
Ordinances and Charter and the Mules o f the Health Department.
He a lth C ommi ssi one r .
Clerk tt Ea a l t h C ommissioner a nd Boird it He a lth.
vided by Ordinance No .110J329.
receiving Burial Certif icates witho ut the signature o f /he Co mmissio ner o r his Cleric, will subject themselves to a.f ine, as pr
* In filling out t he va bove C e r t i f i c a t e -Physi c i a ns are e. ,e st e d t o c onf or m st r i c t ly t o t he Nome nc la t ur e p r i nt e d on t he b a c k .
ir
.J
4
N
1
\
J
s
g
< £
ft
*K>
* n
•S
< »
"K>
« 3
«
S
Si
Ps
6
o.
- S- :
s
o
- K>
£
8
•i< .
o
• K>
* * >
^
s
V
^ >
1
N OMEN clATOR^ ^ fr- l^ Mfe.'^ X• .
OLA- s s i.
S YMOT1C. "
1
ORD ER1.— M i a s m a t i c .
D iarrhcea
D ys entery
f Entero- C olitis
1 Erys ipelas
' Group., ,
1 D iphtheria
Tons ilitis
Fever, Bilious
" C erebro- S pinal....
" C onges tive.
" Hectic
" I ittent '
" Eemittent
" S carlet
" Typhoid
" Typhus
Meas les
Pyaemia
S epticaemia
Toxaemia
\a
V ariola
• V arioloid
Whooping C ough
ORD ER2. — En t het i c or In oc u-
la t ed.
Malignant Pus tule
Alcoholis m j ManKrpotue:
Inanition. ;
Purpura Itemorrhagica
'i * ORD ER 4;— Bcfrosttie.
Tsenia
V ermes
' j < ' 'V at
"\» Qm eA f. —bi a t li et i c .
" A < r- ~~^ Anaemia , t . .T^ Ti
" Breas t - iV lAJ}
'* Intes tines
" Ovary,
-
ORD ER2,— Tuberc ula r.
Abscess Lumbar
Gangrene
Hydrocephalus
" (C hronic)
Phthis is Pulmo.mUis
S crofula
Tabes Mes enterica
TubeicularBionchitis
• ' Enteritis
" Laryngitis
" Meningitis
" Peritonitis
OL.A.J3 S 3 .
LOC AL.
- ORD ERI,— Nervous .
Atrophy (S pinal) ;......
Apoplexy, C erebral
Apoplexy
C onges tion of Brain
Epileps y
Inflammation of Brain
"• C erebro- S pinal
Myelitis 1
Hemiplegia
C horea
S oftening Of Brain
jjrr f f •***^F
^ T3 Bft(Wi?^ !fcn4a< orj/. i C
An*gina^ Pectoris |.!.,. <
Aneurism'..'.'. f...^ ..* < ..
D @^ |fW^ }- |« v
Embolis m (C erebral) .* ,
Endocarditis
Fatty D egeneration of Heart-
Heart- C lot r,....
Hypertrophy of Heart
Thrombos is , (Pulmonary)
V alvularD iseaseof Heart
ORD ER 3,-~Res pi ra t ory.
Bronchitis
Hydrothorax
" (Typhoid)
ORD ER4. — J'i gea t i ve.
Ascites., „
C olic(Bilious )
Enteritis , C hronic
Gas tro- Enteritis
Gas tritis
Peritonitis
Fatty D egeneration of Liver..
Hepatitis
ORD ER 5i -^~Uri n a i 'y.
C ys titis
D iabetes Mellitus ;..„. ,
f '», ''" f * i J
\ t \ 1, 1 *
,, P^ ostatiiis.....,..",. i^ m^ i
ifrajmia'..^ ..^ ..!'., V (A,.^
^ Oto'^ JS ntfte.0.
^ , J *' * ^ ' M
Metro- Peritonitis (not Puer-
Ovarian Tumor u
. Ovaritis ,.
UterineTumor ,..
ORD ER 7.— Loc om ot ory
Os s eous .
'
Lordos is (C ervical)
/ ^ ORD ER8. — Loc om ot on f^lfn t e^^
m en t a ry. . * j j r4
''/' *^ ^
C arbuncle,. ..Ig...^ , C . ". »
C ellulitis .X ^ rf....X
y " *"»
Eczema (Impetfgmodes ) ^
, P ( >l **" '• " .
D EV ELOPMEN TAL.
ORD ER1 . -^- C hi ldren .
C ongenital D ebility
Haemorrhage(Umbilical)
ORD ER2. — Wom en .
Chlorosis
"/ i " (V omiting)
'Puerperal C onvuls ions
'1) ketritJs ..^ ......;
'*,- . /Peritonitis
" "\ S epticeemia
Exhaus tion i from Tedious
Labor SL .".»
v "
, ORD ER3 .— Olc / f& ge. .
f Gangrene (Senile) 1
OED ER 4.— Nut ri t i on .
As thenia
Atrophy > . . . . .'
CL- A.SS 5.
;k V IOLEN C E.
i^ T>
k OKD E^ R3 .— Vi olen t Dea t hs .
D row'ned ^ Ac^ dental)
filled by.Lightning.
'*• poisoned by
S hock from
S uffocation (Accidental).......
C }
ORD ER3 .— Sui c i de.
S uicide by
Poisoning
Guns hot....
D rowning
C aus enot as certained
Total
S tillborn
Premature Birth
' ' ( • ' I " '
/ V- . JU'fw-is v
,A. D. 188 ^personally
,—,,.,..' '.'.........:"...Ci in and for the aforesaid Qefaxty duly authorized to administer oaths
aged.~C*ifiV-»—years, a resident of
i^the'
whose Post''Office address-is'..
a . aged -i —years, a resident of-
in the County of---"--—™ ., ——-— • —----- —.and State of—-
whose Post Office address is?
well knowntometobereputable and entitled tocredit, and who, being duly sworn, declared inrelation toaforesaid case
as follows:
OTE.—Affiants should stateliow theygaina knowledgeof the facts to which they testify.]
>?%>^..^.<=^^^^
:i^^.:..f^^^
tfg>- <^5i>-Z^:
n/ sy , c / /
.&3^
nointerest in said case and
A
D
D
I
T
I
O
N
A
L

E
V
-
I
D
E
N
C
E
.
P
r
i
n
t
e
d

a
n
d

f
o
r
s
a
l
e

b
y
J
.

H
.

S
O
t
r
t
t
i
;

W
a
s
h
i
n
g
t
o
n
.

D
.
C
.
1 / 4 '' |J .
, f /EAJ CE1J
*f davit is, preparedfrom1 inemojr-knda i
t* ML * " ' ' "
0tdte of-.
Hi-;.- i -• • ^WAVi" V * > * ' '^t v
^^^. ^Pip-fUK' . ' - f "
, |t^y*hand,wfitmg^f ''thjs' afflafityihe marginal instructions
i-'1 ^l^beffaplip 'injpossgSaio'i, of aiffi'ant as to the oragin and
ief'dalj'es'of Ij,tr!ea|m6nt'1sh;c)-gld«b0.l'spe6ifi6ally g|ven. If the affl-
^• ;,! -•
*' % < ,;• ' ' i
»'<,,*;la" ' • ' .
^i<y$.',lV\>-' {;
off-.
In the Pension Claim No.--
(pompanyand regiment of service, iMn the army; and rank il In tnenavy.)
' , t I', *
,, 4 -VS , V. f5 ' ' ' ' "; ' X>^ "V^' ' , ii » ' ^^ <Sf-^ ' 4 ' S ' t"' (' ' '
Mp'>". , !'" ' Per^lljycame;,befpre me,a,....-~:.^£l^:!^^ f6r the
»/«*'/'• "
whose;PostiO%ief^Jiaii»es^ is-
well known to; meto1 be reputable and entitled to credit, and who, beingdulysworn, declares in relation to aforesaid case
as follows:
That he is a PracticingPhysician, and that he has been acquainted with said soldier for about —X-------- years, and that t —X-- ------
(Here embodyall the fapts known to the affiant In accordancewiththe marginal instructions. No erasures or interlineations will be permitted
" * x?" X t
unless the magistrate certiaes in ms jurat that theywere^made beforeexecutingthe paper
/
of - obs
physical ooiwiti
whether as' l
family physician or
as a neighbor; and
how near he has
lived >to him. If
he knew that the
soldier was a sound
mam at enlistment,
he should so state.
adding, if true,that
had he" been un-
soun<l,
haveknown it.
If he treated
claimant while in
the seivioe either
'as hid regimental
surgeon or while
"olainiant was home
on 'furlough, that
fact should be
stated. Tbeolatta-
ant's physical
condition top such
times'shoula'.'be
clearl
Of HI0
" and'date? ofytwat-
' ment
He further declares that he has been a practitioner of medicine for f&G&**?^. years, and that he has no
interest, either direct or indirect, in the prosecution of this claim.
( A ffiant' s Signature. Give rank and service, if in the army.)
Sworn to and subscribed before me this ...... ....^"... ............... day of ......... ' ^ i f f f ^ i f - ............................................ A . D. 188 S2-
/ x
and I hereby certify that the affiant is a practicing physician in good professional standing; that the
contents of the above declaration, &c., were fully made known to him before swearing, meteding tho wejds
.ad^ed; ..and that I have no interest, direct or indirect, in the
prosecution of thi
W&f
,
'
( O fficial Signature.)
••—V,
, ,,, ..,.,11, , c
t• .' * • ,-• ' v « . l' ( " ' » !>
,' ":t* -li > ! '
(gMoial Character.)
./- .. Clerk of the County Court in and for aforesaid County
and State, do certify that , Esq., who has signed his name to the
foregoing declaration and affidavit was at the time of so doing— — - ; in and
for said County and State, duly commissioned and sworn; that all his official acts are entitled to full faith and credit, and
that his signature thereunto is genuine.
Witness my hand and seal oi office, this— ... .'day of , 188
[L- S.] Clerk of the
, NO TE.— This should be Sworn to toef6re a CLERK 'Sp CO URT,"NO TA RY' PUBLIC oV 'trUSTICE O F THE PEA CE.
If before a JUSTICE or NO TA RY, then CLERK O F CO UNTY CO URT must add his certificate of character hereon, and
not on a separatetslip of-;paper. • '
. s,N*Jt*« <ws$W#**< >^*i»U»!• *
u
w
Q
U
w
7 ';
fiM
£• S'
, B
Si
S
£&_..; %rtttjt8?<j;
^.iJsSSarifeS^t^^t* ';,
* > - i ,
. D. ISS^personallyappeared before me ' j ' ' , , / „ , ON THIS
fa
. in and for the aforesaid B tiu iL liy du ly au thorized to' administer oaths,
-S
-aged— rtdsaat-years, a resident <^^^^f^S^^^..,.!^r^....^.!r^^-^. i \
,' ,- i*
"'Vl
in the Cou nty of'-*° -.-T: - and State of .-
\\hoso Post Office address is ,-•
well known tome tobe repu table and entitled to credit, and who, being du ly sworn, declared inrelation to aforesaid case
as follows:
V^.^ _^
NOTE .—A ffiants shou ld state liow theygain a knowledgeof the facts to whioh they te
ix2£g!2£fe ^^^..,.^^^^'.
, ii j h 'r ^ ' ' ^ '.f T. > ^ ' , ' ^ . < ri \
"-"y . ~~'.3t ~«*^- -^ez*a
x...^".<^^^4^si.^L^^r...^^
i 1I1,^/1v . /7^ ^/ ^.
tp prosecu tion, ,^5>
_^ , < j ; < i
? \
..!'V fSfrlt?'!' , > , , / , , < " ' , ' i\J - ' > ' , ' /' , - ; ". **! ' ' ' - T^' • H ''
A
D
D
I
T
I
O
N
A
L

E
V
I
D
E
N
C
E
.
P
r
i
n
t
e
d

a
n
d

f
o
r

s
a
l
e
b
y

J
-

B
C
.
S
O
U
t
E
,
"
W
a
s
h
i
n
g
t
o
n
.

B
.C
.
2

H
r
i

"
^
s
"
D
"
^
S
g
f
e
?
H
o
§
1
8
^
c
h
£
>
^

v
^
^
8
c
T
«
§
g
i
f
1
%
s
?
a
y
f
S
1
§
K
O
B
)
t1
^
i
sl
i
2
«
t
r
-
f
f
i
C
D

fej
f
a
g
o
!
.
«
PD
O
S
'
IBI
Q
Io
Qop
*
£
'
og
-
S
o
0
5
I
'
ff?P
<
r+
-

1

i
OPIP
i
P
.
5fPI
-
y
-
.
;
-
^
i
g
,
;
-
j
i
L
.
.
.
Widow's/ Declaration;
i m u st b e E x ecu ted b ef ore ^ou ri' o;
; Pension 'or Increase of Pension. '
R ecord or som e O f f icer th ereof h av ing ' C u stody , of th e S eal.
1
,00: S tate
O N THIS day of . ...C/.&f&CZ^t&ttl.................._ ........ A. D. one th ou sand eig h t h u ndred and ei
personally appeared b ef ore m e -C W?-Af e?^x ...................................................... of
of R ecord with in and f or t h e- t owand S tate af oresaid
_.Q , ag ed ....^}....O , y ears, wh o, b eing du ly sworn according to law, m akes th e f ollowing declaration in order to ob tain th e
/
Pensjon prov ided b y Acts of C ong ress g ranting pension to widows: Th at sh e is th e widow of .. /"x ^ ^/szsy^—/^
/- /^ ~ ~ 1 ? /^
.., •tfaokfrl.^£.&? .££.-..u nder th e nam e
^...^^^Jf^^...ff^f^^^^.^...^....^.^...^ , oi^th e /.^y ^^day j
^ -sfZ^Z- ^f? _ / „ (["_ „ ;-?
in ../.^__C2..-
(C om pany and R eg im ent of serv ice, if ^n th e 5-erressel and rank if in th e nav y .)
in th e war of Z..4Z^.<... ..rrZT~../:...£L..«S ..eJ wh o
(S tate natu re of wou nds and all circu m stances attending th em , or th e
i and m am ier in wh ich it was Incu rred, in eith er case sh owing soldier's death to h av e b een th e sequ
- ' v . , ,^ ~
on th e
wh o b ore at th e tim e of h is death th e rank of
( I n th e serv ice af oresaid." or oth erwise.)
...to Said.....rrb ?^<^>^^2:c^ th at sh e was m arried u nder th e
on th e r^~ ..,..^r. day of
ere b eing no leg al
b arrier to su ch m arriag e; th at neith er sh e nor h er h u sb and h ad b een prev iou sly m arried
(If eith er h av e b een prev iou sly m arried, so state.
and g iv e date of death or div orce of f orm er spou se.
th at sh e h as to present date rem ained h is widow; th at th e f ollowing are th e nam es and dates of b irth of all h is leg itim ate
ch ildren y et su rv iv ing wh o were u nder six teen y ears of ag e at f ath er's death , v iz:
of soldier b y .C ^^r^?^?;r»se2^f e^rS «rrr..., b orn.^A£--^~-~/--~-- 1 8
if soldier b y .tjf. (/.. , b orn ..£
c ^ ^
.of soldier b y J\b 6rn ..1 8
of soldier b y . .^1 , b orn J\8
of soldier b y .A, . , b orn :l.---....^f .-=iv . L_ ., ...:. 1 8
of soldier b y .. , J^i..... , b orn _ _ X — 1 8
. of soldier b y .. ':..... , b orn \8
Th at sh e h as not ab andoned th e su pport of any one of h er ch ildren, b u t th at th ey are still u nder h er care or m aintenance.
(F or su ch ch ildren as are not u nder h er care claim ant sh ou ld accou nt.)
th at sh e h as not in any m anner eng ag ed in, or aided or ab etted, th e reb ellion in th e United S tates; th at.....?.!!IZ^2r^rj?^'!"^~:
S /s? ^ ~">f^ ^*/s S* ^ ^ /^ ^"*^ Sj's?
prior application h as b een f iled £%^-<££^? ? ? Z^^^
(If prior application h as b een f iled, eith er b y soldier or widow, so state, g iv ing nu m b er assig ned to it.)
:^.,.y ^(..j£,g2?.
/
th at sh e h ereb y appoints with f u ll power of su b stitu tion and rev ocation,
h er attorney to prosecu te th e ab ov e claim ; th at l|)(f f residence is
and h er'Post O f f ldb 'address is
,
(Two witnesseswh o.ci
Also per s o nal l y appeared..;J
res i di ng &l..c&..<&&.^..-'&&f<(<d4f3<**ttrf. yy/(A£&?7TT. .persons whom I certify to be
/fan ~~f"—
raspectable and entitled to credit, and who, bei ng by me fiiiiy'swOfn, say that they" were preient and saw -./OOrf5£2T^&*£^t<l-.
I S &L ) . '.., the claimant sign her name (mafre-'hcr mark) to the foregoing
decl aration; that they have every reason to bel i eve fro-m the appe'arance of said claimant and their acquaintance wi th her t hat
she is the i denti cal rjerson she represents hersel f to be ; and t hat -t hey have no-i nterest in .the prosecutioni :0f this claim,- • • > .-• • ; •
(If Affi ants sign by mart, two persons who Can write"sign here.) - : '
3t*??kZr%d*<^t,...<Z?^^
" ' • (Signature o f Affiants.)
[L. 8.]
Sworn to and subscribed before me this.y«l5*£.~"^_\.—......day 6t.^.&&&T~z^&???4/^..... A. D. 188<fT..,
and I hereby certify that the contents of the above declaration, &c., were fal l y made kn o wn and expl ai ned to
the applicant and witnesses before swearing, i ncl udi ng the words t _.^
..erased, and the words.,
prosecution of this claim..
...added; and that I havW n'6 interest, direct or i ndi rect in the
0
fl-
H
O
)-H
CO
^
W
S
'04
GENERAL
p"
, 00: State o f &J^L#^<xi*6*t. _ _ . , Co uritg o f -
In the matter o f ,.
ON THIS . . . . . . . «. . . . . . . . . . . . . . . . . . . . . . . day o f A. I). 188?"; perso nally appeared bef o r e me
in and f o r the af o resaid Co xinty duly autho ri zed to administer o atns,
. ^9
aged S *- f f ~ year s, a r esi dent o f .•J?£^^^if iilf ^- 2^^^^^i
'in the Co unty o f'^^. <^^rffe. - - ^s^te^ii?!'. . . . . . ~ . . . . . . . . . . . . . . . . . . . . and State o f
well kno wn to me to be reputable andentitledto o i'edit, and who , being duly swo r n, declared in relatio n to af o r esai dcuse
as f o llo ws:
[ NOTE. — Af f iants sho u ld state lio»?r theygain & kno wledg e o f then*trts to whio h'they t e st i f y. ]
y/?
^JQ . O interest in said case and - rl!?f!T*^Vrr3*it!r- . . ;. . no t co ncerned
in its pro secutio n.
( I t Af f i a nt s sign by mar k, two perso ns who can wr i t e si f t n here.
P
r
i
n
t
e
d

a
n
d

f
o
r
s
a
l
e

b
y

J
-

H
.

S
O
P
t
B
,

W
a
s
h
i
n
g
t
o
n
,

D
.

0
.
II
l
i
E
h
s
o
o
c
c
t-3
Io
(3-56O.)
APPLICATION FOR ACCRU E D PENSION.
(WIDOWS.)
^Olinifl OjJ&J&£3^&-.rte-&r£<^&_____, Ss:
clay Qi ....^^f^.^^pf. , 188^personally appeared
-., "who, being dul y sworn, declares that she is the law ful w idow of
., deceased; th at hedied onthe ^ferr. day
c~ i x- f~ V v^7 ,s\ y~ / * >
of .^-^^fdAdd^^U/IA^^ is./ J.; th at hehad beengranted a pensionby CertificateFo. Zx^«-^l £ _ - £ _ .
I i ~ t/ ./ &, -^J ' •—?*- *./ ^
which^rs herewith returned (or if not, state why not) ..^^...tfT^jZ^.t^^^fc^ —'
; th at hehad been paid the pension by the Pension
A gent at,/ .t/ ^^.LA2/ ._/ .L-^'^-----. up to the . _ _ _ > #—— day of
\_s
after w h ich date h e h ad not been employed or paid in th e A rmy, N avy, or Marine serviceof th e U nited
StateSiNkeajp^t- ^ / - •?- ; th at
Jb /t(, S/? ' // J?
she was, married to the said ^<^.-^> ^^^.A^r^.<^i-ri^r^C~^?2t^-..onthe ^v.<f^^^7^^-.— ^»^
in the Stateof
/
.; th at her name before said marriage was ..j^*?^f^S^f^:^.^
..; that shei»^^had not) been previously married; that her h usband
3 hacF not) been previously married; th at she h ereby makes application for the pensionw h ich had
accrued onaforesaid certificate to the date of death; and that her residence^is No
street, -City of. - " —. - '—r',-V-': ., C ounty of .
of.._^.^2^^^t^3e^^^ef. , and her P ost- office address is
, State
/
/ $ / V "
Mow's signature:) ^(/C/(^7^^7 <3^ ~4J/i^C™^' j5«^?tT-
.(/ - ,-?
' /">x // , JS ' /
Also personally appeared ..^.{£^^^u^^^^/^^^SL£^9-fffj^, residing at ^Q^-^h^-^^T'^
J£ ( / / *r/ ' s
.., andv37?!g?i?5?^2<^---<r^-<~<* -?r±fi2^ at
^ w h o, being duly sw orn, say th at they were present and saw
. sign heE-aaine-(inakc her marls)-to the foregoing declaration;
that th ey know her to be the law ful widaw of !ti_^<?L/ L^/ .&^J^5^^ , whodied
on the .-.../f-frp^. day of If^d^Ad^Q^^l.^ 1S<Q._; and th at th eir meansof know ledge
th at said parties were h usband and vrifg, and th at the h usband died on said date, are as fol l ow s:
.^^S3^^!l^£^^ ^^^,-
. x y / S /^ ,t—^ ' /^x s? , 7
. S w orn to and subscribed beforeme on this .^..-^—f. day of .
and I certify th at th e affiants arereputable persons; th at th ey know th e contents of their depositions,and
th at th eir statements are entitled tofull faith and credit. I furth er certify th at I h avenointerest, direct
or indirect, in the aboveclaim. "' ' "'•
(Signature:)
3:t—5M.)
(Ojfieial character:)
c
A
P
P
L
I
C
A
T
I
O
N

F
O
R

A
C
C
R
U
E
D

P
E
N
S
I
O
N
,


(
W
I
D
O
W
S
.
)
C
e
r
t
i
f
i
c
a
t
e

J
V
o
.
c
-

'O

~

2
;
ffi
S

%

5
=
3

2

-
.

'3
"



S
3
S
~

^

S
.

t
r

~

-
^

2

^
<
r
a

S
'
»

S
'
S
"

^

'

&

5
T
i

p
,

5
'

S
3
»

g
.

g

e
C
D
C
D
S
T
S
^
g

£
!•

-
f
-
&

g

r
t
>

t
!

C
D
^

S
-

i
r
M

"•*

j
r

S
3

-3
-

w

t
o

i-
i

2

C
D
8
=

o

0

=
±

°


S
'
-
S
^
^
H
^
^
S
'
!
C
D

w
^

•—
'•

'-
'
!Z

C
r"

E
r*

^
s

S
^
w

o

r"
|3

C
D

jr

jr

,-»
.
.-.
r
*

/
s

2

_

^

*

^

5
:

£
p
"
S
"
K
B
^
B
S
.
c
i
S
g
-
|
.

g
|
j
§
|
_
B
^
|
-
=
f

S

1
3

5
"

B

S

£

s
L

"
>
»

-


E
±

&

3
:!

o

5
.

2
.

*
-
"

p
j
.

g
^
g
.
^
s
^
-
c
f
t
-
a
o
3
.

=
<
!
Q

t
<

o

C
D

C
B

C
D
<
r>
-
c
r
S
!
M
3
p
J
p
'
2
p

i —

O

O

K

p
S

c
J
L
&
^
p
-
S
S
'
J
L
0
=

F
T
&
C
D
?
C
D
"
B
C
D

'

5

^

_

^




>
C
a

<
5
o
^
o
£
,

C
D
0
3

o
;
5
p
-
0
c
D
2
-

3
1
'
:

I

g

2

1

$

?

|
:
±
j
:
C
D
^
^
P
C
D

•—
E



i
^
O
5
3
O
P
C
"

r
-
.
"~
^

.


S

i-S

S
3

c
j
0
3
c
r
.

p
-
P
^
^
s
q

^
C
D

.
C
D

r
+

C
D

Q

O

p
&

'

5
f
D
5
'
c
D
r
i
-
,

M
S

'
^

ffi
J
-

3

S

ffi
®




w

c

*
3

2
.

S
3

o

^
r
t
-

p
-
p
C
D
r
r
g
q
g
.


°

0
=

S

|
.

5

«


g
"

^
p
J



?
B
O
»
S
^

o
2
-

S
'
3

P
1

C
D

8
3

^
,


g
-

,
g
.

|

»

»

g

2

o
;

^
-
'
^
^

~
j
O

.-•

•"~
J
<
C
J
*


j—
*
"
O
*

C
D

_
_
.
^
-
i.

§
-

»

*

&

S
-

o

°

«
2

1

S

'

o
|

8

§
^

>
S

<
j
o

g
~

o

2

E
'
e

:
S

g
,

"


r
f

S
'
&
.

S
C

:

£



=
*

B

^



5
g

'

^

5

§

&

o

c
B

t
f

B

5

"
'

0
C
D

>
<

7
*

Q

f-*
^
v
*
>

5

U
' '
*-3

>—
^

C
*

'"S
B

P
J

X

E
-
O
p
C
D

-
g
B

0

?
&

^

S

»
,
2
.

S
5

S

o
i-3

r3

'-s

p
i
B

.

g

a

£
8
3

S

C
3
^

'

d
i

r~
t~

n
F
f
i

'

r
r
i
O

>
i
0
5

&

S
3

0
*
&

o
"

o

,
5
0
e


&

r

s

f
i —
'
P
^

C
D

w

-.L
I
&

C
D

1
-3

*
-3

f
^
c
c
p
'

J(-1
-
»
'
a
~
J
P
Q

S
M

£
S
.

K

S
c
^

^(-1
-
P

C
D
'•"1
"

M

"
1
.

1
i
"

s
.
&

'D
c
t-
C
D
O
0
3


I
-
'
ao^ ^
^
"
i
-
o
,
^
r
i-

t
^
-
S
<^
ir
1
-

¥

f
^cO

c
"^

p
=
:

-

1
'
C
D
C
D

^
2
.

6
r
f

^
O

P
~

p
c
E

p
j
&r
i-
E
*
^
j

&
1
&

0
<
!

0
O


^

3S
c
*
2
.
o

_
^aC
D
OC
25
-
<

-
B3r
^
j
X•D
"
1
3
3
=
1
3
^
J
O;
"
13
-
*
$
r+
-
^3
s
'
1
J^
:s/
i
g

f
i
-
o
V
£
^
3
OO

s
301
-1
3
r
i-
=

t
f
i
?
"

*
^

tt
a*
^
?&f
e
••^
*

*
s
^
•o
i*
t
o
*
*
*
^
^
i
IS
o
f,
State
.^AFFIDAVIT.
^=fc
ON THIS
' < * " • # ' *
..... :(3<*«*5SS5r. ...... <••*&
j < Z i — / /"// / *r
/ ....„...! day of... ^K^^k^^- L A. D. 188 y\yappeared before me
r.; < ,,in and for the aforesaid County duly authorized to administer oaths,
||l::;
2fe;f!W*3^.,..j«£*^.^J^!C^.:?ir^h aged ..«?i.i . years, aresident of c
in the County of ,_^^rss£r^2>sfe*s?'. and State of
whose Post Office address is
X
aged
in the County of jc^r*- o^j^-z^z^isz? and State of
years, a resident of: .e^^^r.,^^f^^< ^r^^:.
whose Post Office address is^j^^Tj^-fet^TT.^^
X
well known to me to be reputable and entitled to credit, and who, being duly.sworn, declared in relation, to aforesaid case as
follows:
[NOTE—Affiants should state how theygain a knowledge of the facts to which they testify.]
i
's
^jt^r.f
H
' fv
further declare that
.
..no interest in said case and
its prosecution.
not concerned in
Affiants slffri b^mark, two persons who can write si^n here.)
S T A T E or <s>^^^^<^...<fexf*fesfefe....,v. ......i.J , C O U N T Y O P .,
r | I f r
S worn to and subscribed before* me this day by the above nanjed affiant , and I certify that I read said affidavit to said
,, _ '. added
and acquainted ..../*?&frKt' ......... with its contents1hefore.,.—^Z4ii<'. ................ executed the same. I further certify that I am in
nowise Interested in said case, nor am I concerned in its prosecution ; and that said affiant.^.....'3 x 3 < < € .- .......... personally known
to me and tha.t..j&>(.....4&ttZ. ........... credible person.^
( O ffiflfal C haracter.)
I,.. ,.J?,.Z.- n., .: ,U ^,^.,./...,/...<S rr.^r^.c,..r±r^:±^- C lerk of the C ounty C ourt in and for aforesaid C ounty
and S tate, do certify that ^LJ.^^^^r^:!?.. ^.^^^d^^,, , E sq., who hassigned his name to the
in and
for said C ounty and S tate, duly commissioned and sworn ; that all his official acts are entitled to full faith and credit, and that
his signature thereunto is genuine. ^—
foregoing declaration and affidavit was at the time of so doing -- fr^^ ."^....?fi£T*TV'... .._(?^~~^*~~*- - *—~€—' jt;
[L. S .]
Witness my hand and seal of office, this h^ day of.
C lerk of the
N O T E .—T his should be sworn to before a C LE RK O F C O U RT , N O T A RY PU BLIC or'JU S T IC E . O F T HE PE A C E .
If before a JU S T IC E or N O T A RY , then C LE RK O F C O U N T Y C O U RT must odd his certificate of character hereon, and
not on a separate slip of paper.
Kf-Wfl
o
a
a
Q
$
W
z
o
If*
h
>— I
Q
GENERAL: AFFIDAVIT.
State of
In the matter of W-ML0tCtft^tg*. "&*
of ., 00
ON THIS / day of . ..A. D. 188 5f personally appeared before me
in and for the aforesaid County duly authorized to administer oatha,
.s
aged .years, a resident of.....^fZtJrr-?r^^2-..<^rr-^rr^T^?T
ih the County of ^cfess^tz-^fes?. - and State Of
well kno wn to me to be reputable, and .entitled to credit, and who, being duly sworn, declared in relation to aforesaid case
as f o llo ws: (2-^%,,st^^ «Jr
[Nora—AfRants uld state ho^? the^ata a kjit6wleage of the facts to %Jiibh they testify.]
'^£ * * < — £ - e- ^&t.
Post Of f ice address is.
i
.f urther declare that
ita .prosecution.
u
[If Affiants sign by mark, two persons;who can write sign here.] [Signatur
A
D
D
I
T
I
O
N
A
L

E
V
I
D
E
N
C
E
.
F
I
L
E
D

B
Y
/
P
r
i
n
t
e
d

a
n
d

t
a
r

s
a
l
e

b
y

J
.

T
i
,

8
O
U
L
K
,
W
a
s
h
i
n
g
t
o
n
,

D
.
C
.
I
:
o
o
c
!
^
XO
H
d~
t
d
K
'
g
o

O
25
-

o
§
0
g
1
^
"

1
-3
I
S
"
SB•O
.
o»-<5
O
IgoB
i
a
pBP
-
g
.
^f
f
i
E
t
BoB0
5
1
!
!
!
ACT OF MARCH 3, 1883.
INCREASE OF INVALID PENSION.
•Rank,
Company,
Regiment,
Attorney not recognized. J V o fee payable.
Rate, $24: per month, commencing March3, 1883.
. . v / ^
Disabled
Resulting in total disability, such iia to'rander
Submitted ..... , 1883, ly eJ ...¥.S£.f./3^J fc{j^.. ..... ... Examiner.
Approved.. .............. '._ _ _ _ _ _ _ _ _ _ _ _ ...... . ............... r r ~ r r r ^r f c r ......_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , Reviewer.
ACT AU G U ST 4,1686
I
V
8
"
8

4
v
^

^
\
-s&2*&&c*j**L.
^4
s£j^
.-(-^>
S S /
-£3££tyc£e&
~&*^te.J..£-..£&e*L.^£~
'4£**j(.g..j2e e^*^^/<£-
</v
-~xs5^ f^L**CJ& ,
<^^.- ffc&t^fl^??r4^? &L~-/&3^t>
&btsfr 0djrl^£cSl>t4- .*-
P'
R. ,p. DRUM,
Adjutant General,. '
Adjutant Senegal.
J (a) /
'X1
f
r
-
c
'CASE OF AN OBIG-INAL APPLICANT.
No. of Application, /£>f/
Applicant's ser
Vice.
en Me teivice o,
tnva
'ate£, w - fio ( 4 an APPU CANT
/•/ J • / / / / / / ' /'#',
nv- aua neiMion} fat ieaton of atteaed aw afoMw i&utuina ifiom
/
Degree of disa-
bility.
Origin.
"Probable dura-
tion.
Particular do-
fioription.
4at'a
tncafiacitalea /o.
/
e caade avove
/
' S' / /' •
om fi( 4 nietent conaw <?on, a
ifaoaui'P aetciififoon o e attcanfo con
/ comMeaton,
9 /
r Examining Surgeon
1 URGEON'SrCEETIFIOATE 1
CASE
Co? ., Reg't,.
AP P L I CATI ON FOR P ENSI ON.
No. „../.
BATE OF EXAMINATION,
Mxamining Surgeon.
RECORD AND PENSION DIVISION,
Washington, D. C.,
[TRANSCRIPT FROM RECORDS.]
<ttj^?p,pears from the records filed in this Office, that
C-^?3<*«*dfe. Go.J^r. , &... Reg't.
\v€slidmitted to &&<$$ft&&!3^1^:. Hospital,
for treatment for
fc^..r/0<<^fe?k*?fcsSJ<i^^
...(£.<wfa^_J?^^
fesnto«....^(S.«SS««^^
.<&fe
By order of the Surgeon General:
Vol.
.Breo>. Lieut. Col. and 4ss«. Suryeon, U. S. Army.
(99) '
Ho.
(M oTB. — This cert if icat e should hot be de t a che d i'roBl the accompanying papers, If additional information is deaired relative to
the case, tills paper should accompany tile application therefor. )
No.
NAME OF CLAIMANT,
NAME OF SOLDIER,
^-.-Z^X^^-Z'—
(12172—50 M.) o 6—190

Sign up to vote on this title
UsefulNot useful