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Dear Patron:

We' regret that the enclosed photocopies are the best we were able to obtain using our normal reproduction process. This is caused primarily by the age and faded conditions of some of the documents from which these copies were made.

COMPLETE FILE ENCLOSED


BEST AVAILABLE COPY.

Address your reply to the COMMISSIONER Of ENSIONS "with return of this letter.

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WAR DEPARTMENT,

jjnrgeon (general's
RECORD AND PENSION DIVISION,

SIS:

Washington, D. C.,

I have tl/ie honor to return herewith your request for a report of hospital treatment in Claim JVo. ^A(/j.. /Tr^/lv this Office, , with such information as is furnished by the records filed in

viz: that ^_<?^4^t&^^

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J3y order of the Surgeon General:


To the

Assistant Surgeon, U. S. Army

Commissioner of Pensions.

O (INVALID.)

PENSION

OFFICE,

teatmenJ ?

en i,

a^Zstezz^L,

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11(),3>J976,000.]

03"Address : " Chief of the Record and Pension Office, War Department, Washington, D. C."

WAR DEPARTMENT,

Washington, _^_L:J___iJl, Respectfully returned to the

Commissioner of Pensions,
with the information that ._**;

Respectfully

referred to the] Cfii <f of the War Department,

Record and Pension Office,

u
\

requesting a full military and medical history

(Descriptive list.)

*fc'__'_L-T^nr-^_,!._".-_l_ll,''-!-!.i_'nij---,of the soldier.

Please examine all records likely to afford any information as to diseases, wounds, or

injuries incurred by him while in the service. No other Keptort on file.

BY AVITHOKITY OF THE SECRETARY OF WAK:

Colonel, U. S. Army, Chief of

Office.

(323)

PHYSICIAN^AFFIDAVI'J1.
NOTE.The affidavit should, if possible, be in the handwriting of the Affiant; the marffitli should be carefully observed before writing out the statement. All the facts in possession of affiant as to' the , ance of the disability should bs fully set forth, and the dates o'f treatment should be specifically given, prepared from an account or memoranda in possession of the physician, that fact should be stated.

^~

IN THE PENSION CLAIM

(Company and ,Regiment of service, if in the Arrfiy, or Vessel and Rank if in the^favy.] Personally came before me, a aforesaid County and State,

fiKft

V'

-*&

whose. Residence and Post Office address is. well known to me to be reputable and entitled to credit, and who, being duly sworn, declares in relation to aforesaid case as follows: That he is a Practicing Physician, and has been acquainted with said soldier for about T^. years, and that

[Here embody all the facts known to the-arfiaht.,,ifi accordance with the marginal instructions. No erasures or interlineations will be permitted,
: Ill's Affi-

iow the following itiuta: 1st. Whether or not he knew the soldier prior to enlistment; the length of time he has known him; how intimately and what opportunities he has had of observing his physical condition, whether as his family physician or as a nei; bor, and how near he has lived to him. If he knew that the soldier was a sound man at en- listment, he should so state, adding, if true, that had he been unsound he would .have known it. 3d. If he treated the soldier while in the service, either as his regi- mental surgeon or while the soldier was home on ~~ ' "J-il""t fact should he soldier's i d i t i o n at i should be * i "i"1 hi, a wett ! of his disad a t e s of 3d. If he has treated _the soldier since discharged, he should so state, giving the date of his first treatment; what his physical condition ' was at the time, with a complete diagnosis of the disability; the period during which he treated him should be stated, with dates, as near as possible, of the prescriptions or advice. 4th. He should state the extent to which sol- dier has been unable to perform manual labor, and should compare the degree of disability ex. isting during each year to that which would result from the loss of an arm or leg, hand or foot, ' thumb, finger or toe, as the case may be,accordingtohisbest judgment.

unless the magistrate certifies in his jurat that they were made before executing the paper.]

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....<ff.^

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./fcrf^fcfcA***-.^ Ajiafe: ^ .../4-fc

He further declares that he has been a practitioner of medicine for Jhe prosecution of this claim.

.years, and that he has no interest either direct or indirect in

'_ Affiant's signature.

Give rank and service if in the army.]

'Sworn to and subscribed before me, this

i*"" J Q
<A>.J

day of

i t*&J+^fTl^r/7.7.

, A. D. \9>^*f., 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, in-

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[Official Title.] Clerk of the Court in and for aforesaid County and State, do certify that **,//. ^-} *<S7. {.%/t/.f. t^C/k^1-^ Lr> . foregoing declaration,and affidavit was at the time of so doing &....Mf:tf^f^2.^vi?.'."C,-^-/..tf^f-r?...^K/Cl^^ is genuine. ,.'.' ,...day o f . . . ( * L . . Esq., who hath signed his name to the

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in and for said County and State, duly commissioned and sworn j'Xnat all his official acts are entitled to full faith and credit, and that his signature thereto

Witriess my hand and seal of office, this.,.


fSEAL.]

HIM i

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T>>thiit* nr .Tiistiff < i


e Assi Iture
Ch

o/* the Fence. If before_a Xfi^, i i n |i 'i[ > ,

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(3-145 a.)

ACT OP JUNE 27, 189O.

INVALID

PKNSION.

Rank. '; Company, Regiment,

\JSlSl^V~

I-/

month, commencing ^^^t^-^._. /.../

Disabled

RECOGNIZED ATTORNEY.
Name,
P. O.,
Fee,

Agent to pay. -'_-' 189.

Articles filed,

APPROVALS.
Submitted for proved for

189.2 i...3vL*4f^A^v.,Jf..:.:...._,

&**.

i^t^ji<-*6,

(t/L .J~

now pensioned, under other laws. Last paid to


, 18 , at $ ., for.

'

, 18

-, at

Pensioned from,

(3-145 a.) ACT OF JUNE 27, 189O,

INVALID PENSION.

Rate, $

, per month, commencing

Disabled by

RECOGNIZED ATTORNEY.
Fee, P.

-*< filed,

Agent to pay. , 189.

Articles

APPROVALS.

//

legal Reviewer. ,

Medical Referee.

now pensioned under other laws. Last paid to


Pensioned from , 18 , at $ , for

, 18

, at

SERVICE SHOWN BY RECORD.


.ffc.-fCRe-enlisted .jfi , 18^.^?, &<J? , 18 , honorably discharged honorably discharged.^ , 18

Declaration filed b^L^&t?^-.--./ from

, 189.G., alleges permanent disability, not due to vicious habits,

(TKO.H. MOIMJAN.

IIENKY P. DAVIS.

MORGAN X DAVIS,
ATTORNEYS AT LAW,

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8-1081.

P E N S I O N E R DROPPED.

Knoxville, Tenn

The Commissioner of Pensions. SIR: I have the honor to report that the

above-named pensioner who was last paid

has been dropped because

United States Pension Agent. NOTE.Every name dropped to t>e tl\ reported at once, and when cause of dropping ig death, state date of death when fenown. o-9

DECLARATION FOR INVALID ^PENSION.

\f Jtxrx S5?, 180O.

NOTE.This can be executed before any officer authorized to administer oaths for general purposes. If such officer uses a seal, certificate of Clerk of Court is not necessary. If no seal is used, then such certificate must be attached,

State
ON THIS-WC^/. day of
, A. D. one thousand eight hundred and ninety.

., 0s:

personally appeared before me, a


within and for the County and State aforesaid, i.years, a resident pf the . % County of-

'- ?>
X,

i:i.;' state of .-
1
^ ^S %. rt / \*

dulyigworn aC9rding to law, aeclares that he is the ideiitical

\t said disabilities are not due to his vicious habits, an

(Her>6 state'rank, company and

<",-V
- in the war of the rebellion, and served at least

ninety days, jind was HONORABLY MSCHARfiED at --XZ^^.0?*?3,<X*/^^

on the
unable to earn a support by

/3
day of .-<1>*=6^^>1U*^4&*<!<6^, I8&3. That he \s.-!ubiS~#1L4fr*&t4L^

:ere name the disease or injuries from which disabled.!

<7-

he has

.:.-

Zl

applied for pension under application No..**~GC?~.-~(/--Q-

Thnt hn in. n-pa

(If a pensioner, the Certificate only need be given. If not, give the number of the former application if one was made.)

That he makes this declaration for the purpose of being placed on the pension roll qf the United States under the the provisions of the Act of June^r?, 5^90. He hereby appoints
-Of-

his true and lawful attorney services.

1o prosecute his claim, and he directs that the sum of ten dollars be pai j

! ; County of.....VX...X-*#^^*'^.*t,

Sute of

Sfc
(Two Witnesses who can write, sign here.)

S7

Also personally anpeared/y.^jfc-->

/y> jr

A^t^feSerT^T-fe*^..*^.

, residing atpersons whom I

Bnd.JZ&.4flZK_J!^.JEg^^

at.!^iS?3Br23&^^

certify to be respectable and entitled to credit, and who, being by me duly sworn, say they were present and saw , the claimant, sign his name (or make his mark) to the foregoing declaration; that they have every reason to believe from the appearance of said claimant and their acquaintance with him for ^f^^-f^..

^2_ /)

-years and--

*b_-^:./ *S*!.".'

years, respectively, that he is the

identical person he represents himselfto.be; and that they have no interest in the prosecution of this claim.

Sworn to and subscribed before me this

t^T./.

day of

, A. D. 189-fe?

o
y *

and I hereby certify that the contents of the above declaration, &c., were fully made known and explained to the applicant and witnesses before swearing, including the words . , erased, and the words added; and that I have no interest, direct or indirect, in the

<\n of this claim.

The
1. An.hdnorable discharge (but the Certificate need not be'filed unless called for). ' 2. A minimum service of ninety days. 3. A permanent physical disability not due to vicious habits. (It need not jiaye originated in the service). 4. The rates under the act are graded frorrujtS to $12, proportioned to 'the 'degree of inability to earn a support, and are not affected by the rank held. 5. A pensioner under prior laws may apply under this one, or a pensioner under this one may apply under other laws, but he cannot draw more than ONE pension for the same period.

t+**JcZ? cb^b* a~t<****^-T*&4s<-*^ ^3M*et*+/i/ AA^+A- <^^^r uL**<*Z&.<>t & J-&( *4.ut*iAu*AA 6tf-t**/&Ccd *

4 <>-

t0tate

GENERAL AFFIDAVIT.
55:

ON THIS .^^r.Z^-.^. day of ...^..Z&&<^.. A. K189/, personally appeared before me, a ./ *", / in and ror the aforesaid County, duly authorized to administer oaths, aged..o>xL-.years, a resideift of in the County of /..s?*?*^..g&t*&c,..
-

and State of.

whose Post-Office address is ..r^i2....<2:...!? aged years, a resident of and State of

in the County of.

0 (5

whose Post-Office address is well known to me to be reputable and entitled to credit; and who, being duly sworn, declares in relation to aforesaid case as follows:
[NOTE.Affiants should state how they gala a knowledge of the facts to which they testify.]

^7^^-r?r3grfrfft*^

aR
(D

postoffice address is further declares that.. net concerned in its prosecution.

/V -.........., interest in said case and

C/
lf Affiants sign by mark, two persons who can write sign here.) (Signature of Affiants.)

Sworn to and subscrigea before me this day by the above-named affiant affiant

, and I certify that I read said affidavit to said

, including the words..........................................................;.........................................................................................................................erased,

and the words ............. ._ .................................................................................... _,<>. .................................................................... .................................... added and acquainted .v^^-^rr^?^. with its contents before ...ir/^T.^5^7. executed the same. I further certify that I am in f^Sttd?.. _ personally known

nowise interested in said case, nor am I concerned in its prosecution; and that said affiant to me and tbat......-C?r. &&......&L. credible person.

(Official Signature.)

[L. S.]

(Official Clyfracter.)

^^L

:/..<?2^..JZ

This can be executed before any officer duly qualified to administer oaths.

I, and State, do certify that

__

Clerk of the Court in and for aforesaid County , Esq., who hath signed his name to the _

foregoing declaration and affidavit, was at the time of so doing a

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 thereto is genuine. Witness my hand and seal of office, this day of..

...18

[L. S.]
Clerk of the..

OQ <X CO

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GENERAL AFFIDAVIT.
, (fiauntt)K of ' cSjt> fi

, personally appeared before me, a in and for the aforesaid County, duly authorized to administer oaths, .. aged {&.(#.... years, a resident

.'f, a* nstructions ead the Commissioner of Pensions number '& In the preparation of testimony in support of claims in pension cases, all statements affecting the particular case and not merely formal, must be written or prepared to be typewritten, in the presence of the witness, and from his oral declarations then made to the person who then reduces the testimony to lyriting or then prepares the same to be type-written. And i such testimony must I embody a statement by the witness that such testimony was all written or pro, pared for type-writ\e (as the case may I be) in his presence, [ and only from! his oral statements then made/1 stating also de, place, and _.,, when, where to whom he snob oral nents, and that iking the same t; did not use,- and ,.,as not aided or prompted by any written or printed statement or recital, prepared or dictated By any other person; and not attached as . an exhibit to his tesy timony.

whose Post Office address is. well known to me to be reputable and entitled to credit, and who, being duly sworn, declare case as follows:

in relation to the aforesaid

tiw*l*"*"**>'*>*"!"*"l'

Post Office address is further declared in its prosecution interest in said case and -<*t*

I/

If Affiant

signs fay ma/*, two witnesses w'io can u/n'te si'gn /iet-e

State of

C/....?>Zr^VM^ktxe^^

, County of.

3tA/.
, and I certify that I read said affidavit to said erased, and the

Sworn to and subscribed before me this day by the above-named affiant affiant , including the words

and acquainted

f^^^^i.....with its contents before

.^r^r'

executed the same.

I further certify ^&C/. person

nowise interested in said case, nor am I concerned in its prosecution ; and that said affiant ,to me and that^T*^,.^-?....,.. credible person
//

\S"

Official Signature

[L.S.J
fgpw^g^M^wl-v" - ..*'*

(j*^*~^J^*<~^_^_^^

vv>

, Clerk of the County Court in and for aforesaid County and State, do certify that.. , , Esq., who has signed his name to the in

foregoing declaration and affidavit was at the time of so doing

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
, 189

[L. S.]

Clerk of the. To be executed before some officer authorized to administer oaths for general purposes. The official character and signature of any such officer not required by law to use a seal must he certified by the clerk of the proper court, giving dates of beginning and close of official term.

O O
(4

"3 ID

O co

Joseph H. Hunter, Attorney in Pension and Patent Oases.

DECLARATION FOR ORIGINAL PENSION.


ISOTICK.

0tQtc of..^4^^*^?4^.
.' ' On ihis.r^r. day of..)>^/^^f<^^'. personally appeared before m&,. cs&t&?.l

Countg of
oLthe....4^fr<***^7..*^^^^..^..-

.00,
, a court of record 6....?..

, A. D. one thousand eight hundred and ninety..-^^*^

within arid for the County and State aforesaid* .^<^^r^?>^^^

years, a resident of the of......(2?.^^S^^?^^r^rrr. , County of...(Staje of...>^>^^?r^?r^(...._. , who, being duly sworn according to law, declares that he is^the identical J^^'^^^ was ENROLLED on the.^....day of. <7 / . , _ 'rA/* , / / - ? ' /7^r /^* x0:3..,..,. in Company t^L-....of the v...../..!-^. Regiment of...C^^?-^!?^?...r....fe?...!:?^?^ .^.commanded / x -1// ^ /) (7 t/i x^/ ' ^ ^^^r^^^^and was honorably DISCHARGED at...^^r^^^^ ..on the !t2 day of..2^>(^<^^r^^^8.K...v^.rihat his personal description is as _ / / x? follows : Age,....*/ years; height,..../. feet.../<?....inches; complexion,...JLfkrfr*. ; h&ii^.&r^f****!*?*eyes,...^*-^*^.. That while a member of the organization aforesaid, in the service and in the line of his duty at...v^(^fet/. (/^..<^^z^f^r_ jn the S^ate of...C^;4^***^^;. oil 05,about the day oL.S'^^^^**'..., 18^..4~, he.

;?

That he was treated in hospitals as follows :...

Here state the immes or number?, and the localities of all hospitals in which treated,

That he has. f^'^/^~^t^....been employed in the military or naval service otherwise than as stated above
Here state what the service was, whether prior or subsequent to that stated above, and the dates at which it began and ended.

That since leaving the service this applicant has resided in the..../^^^^-.......of.....< in the State of.......cZ.J^2x^x2rxL/....................; a n ( j n j s occupation has been that of That prior to his entry into the service above named he was a man of good, sound, physical health, being when enrolled a....3r^*r3^^^?r*.*C.-r3.................That he is now. tfici^&f&r^^.....................disabled from obtaining his subsistence by manual labor by reason of his injuries, above described, received in the service of the United States ; and he therefore makes his declaration for the purpose of being placed on the invalid pension roll of the United States. He hereby appoints, with full power of substitution and revocation, JOSEPH H. HUNTER, of Washington, D. C., his true and lawful attorney to OTosecute lijs clajm.
_ _ ffi^&K ^f/^l X'Vv' ' Vro'

That he has

".".. ~............received.....^"~T~r~TT~n~...............allied for aPension.^/ That his Post Office address is -....county oi\..<^^-^^-^<?-2-^'.......State

Claimant's Si
VTTBST :.

.!^I^..

\/r

(OVER.)

CLAIM FOR PENSION

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o

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FILED BY JOSEPH H. HUNTER,


CD

Attorney at Law,

e
p :

AND

Solicitor of Pension and Patent Cases,

:\'

WASHINGTON, D.
CD

'.,'*.

Declaration for an Original Invalid Pension.

-Tfr"'Tr-n'""|VHJS'|:-'~rTrirjitriTJ;rfnr^ranrtnf ur

ON THIS

.--rday of

, A. D. one thousand eight hundred

personally appeared before me within and for the County and StMe aforesaid,.. sworn according to law, declares that hjf is the identical Off , in Company /..X-^of the... commandedl/byj<>i^^/Vr .__... .^ffjt^c ...,. who -w^enrolled on the /Z /& regiment of and was honorably discharged at
day

^......^(^^^k*fr^rr^^-^.
on the 0..

That his personal description is as follows:


:s, eyes /K^+A-*. A" line of duty at or near /W7^vvT6x?xrVJ/^i-

Age ...<?^/ years; height

$.........feet,...&...

inches; com-

That while a member of the organization,aforesaid, in the service and in the State .. 186/^. /Ui/..J&A4sul.. .A^'^fM**^
a woimtl or iujuny, the precise mannw in which received. Hero statoirhc onme <ura nature of Ufa disease, or Uc locatiuii

on or about &e.&l^t?^oL.A14l&.,
aimed." If disabled brfdisease, state/yull;

//6j~

That lie was treated in hospitals as follows ty^^^.^^^..^


1

^ --S^P^WAJL-.V^ ible, the dates ofarrivilland doparuire tVom each.

Here jrtato tlie niui^^oi1 immbers, an^/l.he/localities of all hospitals ni'Vhy'cIi treated, and as near us

<

That he has

.been employed in the military or naval service otherwise than as stated above..

Hfrc stiitc vhat, Die

service was, whether prior or subsequent to that stated above, find the dates at which it began and ended.

That he has not been in the military or naval service of the United States since the ..? That since leaving the service this applicant has resided in the in the State tf..x.j!*fyMSAS~.! .....<<w!^Zr^{<1&f^

- day of of .

, and that his occupation has been that of a

That prior to his entry into the service above named he was a man of good, sound, physical health, being when enrolled a ..................... That he is no\v,..-Sfa/^t% disabled

from obtaining; his subsistence by manual labor by reason of his disabilities, above/described, incurred in the service of the United States; and he therefore makes this declaration for the purpose of having his name placed on the invalid pension roll of the United States. He hereby appoints with full power of substitution and revocation,

J. H. CURTIS OF WASHINGTON, D. C.,


his true and lawful attorney to prosecuteJiis claim. That he has .."""""""that his place of residence is ..\^^ff. s-t/.^st^^j^. vfcvvvf-i receivfid....x^v*t:^C_,applied for a pension ; .^-^....

and post office address is^^f^T^^lZdc.


State of.../^kT/H,

, County 0fL^^^,<<*>?^i--.
^ ,./- \

[Two persons who can write sign here.]

<S. O -A^o personally appeared

..., residing at

(*!&~&M:

, persons whom I certify to be ,. who, being by me duly sworn, say that they were present and saw , the claimant, sign his name (or make his mark) to the

'jsdtd/Yl/'." '^^

aregoing declaration; that they have every reason to believe from the appearance of said claimant and their acquaintance with him that he is the identical person he represents himself to be; and that they Jiave no interest in the prosecution of this claim. ^^

Sworn to and subscribed before me this

day of. ^.tfefc.<^^^^^.. , A. D.

and I hereby certify that the contents of the above declaration, &c.,^were fully made^known^and explained to the applicant and witnesses before swearing, including the words.. C. ... prosecution of this claim.
A

-, erased, and the words

(JL

, added; and that I have no interest, direct or indirect, in the

[L - S ' ]X
tM^r-MlTMtiSlHirii . i ..U.1 li,.rlM^0 t *rW>*>r*^*>~

.im^L^iM/U
/ [Official

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NEIGHBORS' AFFIDAVIT.
For the testimony of EMPLOYEES or N'EAE NEIGHBOES of soldier (other than relatives), showing his present physical disability, as required under the provisions of the Act of June 27, 1890.

State of...QJ<4&^^
In the matter of the application for pension i
>Sf

,&0untg o

;,00.
<^^^

a^^aA^ ..f.

^J/-^^/, ..p.

ON THIS

&...?.~

day ol^

. D. l^S personally appeared before me, a ..in and for the aforesaid County, duly authorized to administer oaths ,... years, a resident of Srs^fe

in the County of LJ......

'*^^,fs*?JS?^^ L ,

and State of..

whose Post Office address is

c?
aged..cjifliji years, a resident of and State of cs4,

and

in the County of whose Post Office address is..

well known to me to be respectable and entitled to credit, and who being duly sworn, declare in relation to the aforesaid case as follows: fori^ years, and */j. been well and personally acquainted years respectively, and that....

Mr

Instructionsread \, The witnesses must state: 1st. T h e i r respective ages and occupation; the length of time they have known the soldier, and how long during that period they have employed, worked with or for him, or lived in the same neighborhood with him and how near to him. 3d. If they have employed or worked with him they should state where it was and at what business; or if they know him as neighbors only they should state about what distance from him they live; how frequently they see him and converse , with him, and how intimate they are, with him, and from what; disease or disability he is; suffering with at present,; and whether at any time! he is obliged to stop work | by reason of his alleged; disabilities. In this -connection, if the witnesses have been his employers, or have worked with him or for him, they should state about what proportion of a sound, ablebodied man's work he is able to dowhether %, ^, J4i %, %* or as the case may be; what his actual earnings are, and whether or not the wages paid him are lst> in amount, and how much less on account of his inability to labor) than is paid t6 others physically sound, and doing the same kind of work. They should also state how they are able to say what his disabilities are, and describe fully and clearly the symptoms as they appear to them in his case; in fact, describe his physical condition fully, and show whether or not he is suffering from a mental or physical disability of a permanent character, not the result of his own Ticious habits, and the extent which he is incapacitated from the performance of manual labor, or the,degree he has been unaltle to earn a support s i n c e the filing of his oiaim.

PS .r^_

further declare t h a t y ^ y

^-.-.. no interest in said case and...... S r < C ..................not concerned

NOTE.The witnesses if not trremselves equal to the Task of drawing the affidavits, should go to some Notary Public, Justice of the Peace, or other officer or competent person, and have the blank filled out and properly executed. STATE OS-1 -, COUNTY

Sworn to and subscribed before meihis day by the above-named affiant, and I certify that I read said affidavit to said , including the words
r^r.'^^^:^iL^^:&'.!f.f^ft---/^^.<*e^.fiSX<*<*^^..r?^?.iry..erased,

and the words

and acquainted *^*<<-<*'*T^...with its contents before- .^r*4^.

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& ^^fe>>m-personally known

_*^ to me and that &\J~*trt.L*&i-

credible i

[L. S.]

[Official Character.]

-Clerk of the County Court in and for aforesaid Count? md State, do certify l\^-----^..,.(l^W-+-s&-&^&^ , Esq., who has signed his name to the in and

foregoing declaration and^affid avit was at the time of so doing.^^^Sl^^fec^<^--/^^f.^^C.t^C.<?r^^-r5

for said County and State, duly commissioned and sworn; that all hisjjjflleial acts are entitled to full faith and credit, and that his signature thereunto is genuine. Witness my hand and seal of office, this-:.

(L. S.J

Clerk of the

/'*/ NOTE.This can be executed before any officer authorized to administer oaths for general purposes. If such officer uses a seal, certificate of Clerk of Court is not necessary. If no seal is used, then such certificate must be attached. - - - "* >+ -' - . >. . ,.- '.,,.,,..,.' - > - ' , -. . .

Q
(x,
CO

oo

h o

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o
4-J

5-jT

State of Tennessee,
I-

County,
Clerk of the County Court of said County,

^ do hereby certify, %hat, whose .genuine signature appears to the attached \^^^syz^^/a^t^^f^r-r: is now, and was, at the time of signing the same, an acting Justice of the Peace in and for said County, duly elected, commissioned, and qualified as such.
WITNESS, my hand, at office, this~/ML...2,. .day of... Clerk.

Nr

Teattoony of Employers, Neighbors or 4c^inta|ices of


f\ [OTHER THAN NEAR RELATIVE^.]

\,

ON THIS .

. d a y o f ..

,,A. D. tS-^^vp^rsonally appeared before u\ a .. Tn and for the aforesaid County; duly authorized to administer oaths *~*'J/ years, a resident of <?p*^? and State of .9

^
whose <P,ost, Office actaieBs Is .

f\p rl

aged
f

years, a resident of - - and State of j^-

e~
"

in th.'0&i|'nty,,of,,.;...,';-.' wtujse Post Qfto'e'^l?^ is, '

"well known to me to be respectable and entitle to credit, and who, being by me duly sjcprn, declare in rela^o; t^^./ ( * *> ? aforesaid case as follows: That cT^^t-^pj; have been well and personally acquainted witj) tor ff^.C., ' Instmot'ioBSi yeai%f .aatdyoarc rcapeullvely, arRl that-'

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WHt .d elor flisate . .fha^otte, 1 JlUrlns;- ftll i |-p>. " - "Va.yi,;wi. rfSny tim< 'gAaper l"fteen QI poii ,-Vi sflierjoo)
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""" "*

AFFIDAVIT OF

."fee 26 l9l

FILED BY

J. M. CURTIS^ :
;

y Prinnipal Examiner and late -Assistant CMefof Division in tneU. S. Pension Bureau.)

WASHINGTON, D. Ci

"'

>;

'W

Testimony of-llmfloyers, Nei^Bors or Aqcpintahces of


[OTHER THAN NEAR RELATIVES.]

OlST f HIS

. - &-*?:. . day of

,; A. D/il8|p^ personally appeared^befofe n|e a

in and for4he aforesftidGoiiili^^d^ly^authorized to admin'ister o^ths

'":./ c-- : .;.::


JBL*~t"

p^*i Jsra^jE

: In ,t||||g||fgsi^fJ ;:ffi:pS,-itu '..' '*-';.*;' : > -%.&!;.'* whose ;'Pos'i' Office; a'diSSss: :

;-.

.-*.

...:,

- - ':.-,--'todVStfti^'pl^'i"^

^.^^...J^^]j^ti:iM^i "':'~: ' " ' .^/'."tt.-*'; .- : ":'-. .


aged,-...

,,...,.

. -and

...L-... years, a ,resident;of .andStateof

in ttee CSuii'fcyJSftf^ .' . ' './f.'.ij :'!?%y":ft.'a?S'


1 wiio^|ES)^ O^c0>ap|;^fe| ti ., ;r

well known to nle; to be respectable and entitle to credit, and who, being by nie:duly sworn, declare in reUtiou^o ' .. '' ^/^ ' . ' . ' ' , ' ' ' : ' ' ''V.'^j-^NX>''y'"^'.^|'^ |! ';j't aforesaid case as:;ipllows: That -rUt^ h<EWbeen well and.personllly acqjaainted^ithV for* ff fe^:-: ; years, .. JiijtoiiotteiUi' ,VEead;C!arsteU!'. The witnesses ^&fi*yeais*espectivelyi and that. .
U-t- >J7

~^~ , f

worKefl with lor him since return from jjhe a'rray-,they should state where ana

/?

_.

tKey Should state It&e Som thoyUvea,

...... <",i)^wdRM1*,Wi((W^

^ffi'^I^C^... (?y>^>!^, ^c.

trtsswiiSiseeib e e n sjiatll^'hjm;; w-liat disease1 or K^fihS&oitel-ea 1 all tiSi^, and 'h'owisever^ly,; whethe aiiafryitime iSg.SaiaperloB, lg|sbeen-cibl$ea tjiS*ist'6;;j? Jisli f|-Jii:gVb:e<l ljijji|e,:rj)r uflable'to do tis&ii-.

_, .'V^ "

/7

^^

y^

.^^r*>^^
' j J / ^n-"t*. - ,. , ..

. ..-

symptoms ,of his disease" or 'disar-

^ii'' "'IL^' ^ ^ ^
'J^i^fc^^fc^.. <^i^&. .42a#2. ,:iliC^?^^f^ .-^. -^^ i'-^^

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AFFIDAVIT OF

ANCE OF'DlSABILITt.

m-

ir-

-I

FILED

^ J. M. CURTIS,: 1 ;

(Formerly Principal Examiner and, late Assistant Otii'ef of Division in theV. S.Pension Em-earn.)

, D. C.

:*&*

_JL.

THIS .-r-r2..1~~ day of

.^^1.^^..

, A. D. ISO/', personally appeared'before me, a

.in and for the aforesaid County, duly authori&d to administer oaths,

d:
""

^*2k.~.aged...<r?:.Q- years, a resident of...

..<!&4>!ei<.
^ a resident ^.--^..^.^.^^^^L
!in the County <tf-v^-!^ .whose Post-Office address.is.,

(fl well known to me to be reputable and, entitled to credit,- and who, -being di^ly sworn, declares in relation -to
\d case as follows: ' '

[NOTE.Affiants should state how they gain a kntfWodge of the 4acts to which they testify.]

p
5

P. g !1
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"f .-r

g, 2.
Q I

AFFIDAVIT OF

I| r 'P

.. , v_LvJ

I
s.
o ^5.

FILED BT:

JOSEPH p. JLUNTER,
&
t?
&
tr1
!

=s -^ t>* c

Attorney at Law,*

Solicitor of Pension and Patent Cases,


S
S" a I O

Lock Drawer 718,

s 9

: WASHINGTON, D. C.

4)

*'

General.

(3O6 DIVISION.

fetoent of tk Ittterio
&

teaeted&ai (/ide GENERAL U. S: A?a it

ADJUTANT

A :_/_Az_!/fe>3^k..
...

/V"

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/_ X\

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x

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3O56.
-- JV?V

**?-<-&- -L.L-*m ^^ jfrtHHutf g*tt"fr


* /irt

' I /wJv<fl'*'&'JI'4W>'JJi'J>l'

Washington, I). C.,

To further aid this Bureau in determining the merits of the above-entitled claim for pension, be kind enough to answer in your own handwriting the following questions, giving more complete details than yonr affidavit affords. > Very respectfully, .//

Commissioner.

When did you first see the soldier after he returned from the army, and how do you fix the date?
ff . ~~r$

Answer :.__J0L*^M!4*^
-Z^l^i^^^

Of what disability did he then complain, and how was he affected? Answer:
A

JM_ - J&0---j?2&O'f---'?*?&-&**?- - - ./3U*r^*rjJr^rfr*afe4^- /*_< *.<W{!.'~- >?a**r. j%*twrff?(, _ **& &**&**?? _*<?*
/

_4-

M M

- ,

-/ . a ^f~

..

y -y -/- /

Did lio continue to suffer from said disability? It' so, please state how frequently yon saw him, whut symptoms you observed, and the extent to which he was disabled for the performance of manual labor during each year. A nswer:, l
^^i^^^fT^1^^

Th*. Cam&SIONER ,OF PENSIONS.


TE. If the witness is unable to write, it is suggested that lie request some competent person to aid him in replying 1o this circular ; his mark to be attested by the postmaster or some other United States official, who should certify (hat the contents-ot the paper were fully made known to the witness before his mark was placed thereon.

o || *|^

6U3&4U&a*~*fje~

K^J^^-^^ / * .>^^<?*i

W^mm^^^ ******>< ^*^1*7Zir

j~^^^^r:l

no^nttrt^xe jo-9^05^90

o? pspi;ua 'uoruido jno ar 'si

>~^

special instructions are forwarded for your information, and when the claimant reports you will re'ad them carefully before maJcing an examination, and return them with your certificate. Very respectfully, THOMAS D. INGRAM,
Medical Referee.

[OVBR.J saofb-^gom

^ t ^

,r
"T
d' figure upon the bflek of cate precisely the location

this certificate

of a disease or injury, the entrance and exit of a missile, an amputation, &c. The absence of a member from a session of a board and the reason therefor, if known, and the name of the absentee, must be indorsed upon each certificate.
ch aracter number of clajm. jtfame and rank & of'claim a at.
3

[Istata above whether for original, increase, or restoration.]

Pension Claim No. _, Rank

<
1*-<^C<
^tf^STTsf^tsd^C.*-

/f

Reg't Qj

[Post-office address of the Board.] Claimant'a postoffice addrebg.

.State,
, 189

a its*.

[D^te of examination.] on.j

hereby certify that in compliance with the requirements of the law/5J have carefully examined tins applicant, who states that he is suffering from the following disability, incurred this wno ne Cause of disa- in the service, viz1: rice, bllity. *
If ji pensioner, fill ill tlif untount; if not,erasu tlie whole liue.

im*rt^~

ffi,

ft-

dstts
[Original, increase, restoration, &c.J

He makes the following statement upon which he bases his claim for

K?re # i v e t h e v \ i in a n t ' s B t"U t e in o n t as briefly and as compairtly cs possible. iZ(S ^(

2L
H?C^

~
Upon examination we find the following objective conditions : Pulse rate, respiration, /<> pounds; age,
Hero give a full description o f

temperature, ,/^-A-; height,

is, in our opinion, entitled to a'


Kate for EA CH '
ra ^ n o

wiir f disa"

^Or tne disability caused by

ztz?^

for that caused

by

, and

for that caused by

_, Pres. N. B.Always forward a certificate of examination whether a disability is found to exist or not.
(37265,000.) 6676

f .

o/ &>-r*^ I
Continue record of examination here.

^-,^ /L*^t^^ sL^*^d-J:Lx-~ sT~

l^mt'Xr tf-*-ar^~~***'J. fj

If^JL

^> /h.

/y, Jjyftot

.J~r~xj&~e yr4f^ #ZL&^^.

\e surgeons will use this blank

They will erase the words "Pres.," "Sec'y," "Treas.," and "Board" where the words appear, and sign at the foot of the certificate, and also on the back of the same. PROVIDED FURTHER, That all examinations shall be thorough and searching, and the certificate contain 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. [Ex* tract from Section 4, Act of Congress approved Jyly 25,

I t

(3-106.)

(,

*' EXAMININ G SURGEON'S CERTIFICATE


IN THE CASE OF AN ORIGINAL APPLICANT.

Name of claimant,
BXAMINING SURGEON'S ADD:

Hank,

Post office, County, State,


__ _, ______________________

-.... hereby certify


S*~**+~-40

fi(ace namea .,_&


Cause of disabilItyandthede- on gree. / , ./ oi aweef me ..

anc/ w/ii<fe in-Swie

/ ''i0 m

/ fl / in condeguence tfteieo/ne ii .
f f ' A

eaindna Of s J / aae. tnat n& wetan /

mancta

tej ana

Mat -foe tj________&T_

incned in neiamt.
, ana

t&edi Auwe-tafo A,e4, mtinufo 0

fi

<Give the rational and physical signs so fully that how and why and how m7itheclaim&nt is disabled shall clearly Appear. When there are neither structural changes nor physical nor rational signs in support " the claim tht.u fact should be stated. The rating should be jnade in compliance with "the "Instructions."

ieveato me fottovetina /act) . S* / / 7'i &^^. CJ^^

.L^&C^LtsZ^ez^t^^ r S* ^ &

f
s ,

. _

5op $

WO

CH

0 Cl - ^

ni
- '

sill

"*^3;tf

Itmustbeborne ..in mind that the duty of the opinion 'won ana* Aitfoiu o/ me claimant, it id Surgeon is to givean opinion aetothepropor- / ana mat it not aaaiawivice 06 vncub, tionate degree UMt 0 & of disability, as !4i K, total, &c., t h r o u g h the grades, without, ftfnii regard to wove a&ioiivea to entitle n>i?n to dollars and cents, and to make such a full particular description as -will afford to this Office the <?/ Examining Surgeon. ground for intelligent opinion and action Always forward a certificate of examination whether a disability is found to exist or not. in rnting.

- SlffiGEON'S CERTIFICATE
IN CASE OF

Application for Pension

Dcrfe q/ Examination :

Post Office,

P. S.Write Post Office address plain and in full.


(11155200 M.) ELECTBO'S.

Cert. No Name?;
.

.OHincLl Roll

Issued Mailed. Rate and Period,

Deductions :.

Issued Mailed Rate and Period, $ ,from.

Deductions:

$ Disability:

e'and Period^ $.

}from

.-..', 18

INDORSEMENS.

Respect/uully

to the

4&^
X.,'

tot

X. j

iie/, Finance Division.

[3216.]

<$% **Va* ' "rfJTF ^' -jJ^^ExV,


v n

INVALID,

Acts of July U, 1862, and March 3,1873.

Enlisted!

., 18

Discharged:

Alleges:.
Re-enlisted;

Attorney; P, 0,...._
-rS^T"
* *M><3SW

L5

Recognized,
r

L- Contract,
4

""^KKT*"!'

,,.,.,-Cert. of Dis.~ ^Searched for ......... ."' ............ .,18 .-, ^^f^^^s^, - "" "

. ^"

'

[3216 a."]

Act of June 27,

189O

twisted: Discharged;
i

plication filed;

n y o t r Claim filed;

Numerical No,

Attorney;

Acts of July U, 1862, and Marctt 3,1873.

Service \< Enlisted:...

^ /7

'/Discharged:
j,' I> * x. <. f

.^Application filed:
v; Alleges;

.f

.. "Recognized,

i Contract,

BUREAU OF PENSIONS,
Washington, !>&>,
,1

No. Claim
- , ^^

Co.

Respectfiffiy

o &-oao.

^^-4;hvU/^'- -';'':'!.!' i'v:;',


feliJrT'^teii.BtviiiL- .' '".' i,

seltaOft1.'

* ''

'
,

';. 3-1461L

'

4'' '
Oertf. No..,.

PENSION.
JNOER "'GENERAL LAW. Eank,./Company, /5v

^ RECOGNIZED ATTORNEY.
Pee, I ; Agent to pay. filed _ ___ , 18..

P. 0.',..
1

Articles

\'. ': j for:-,prj ".(Approved j> ' ' of *"* '^" vl . A '-'i ' ''' '

,,/;.,.,.-' ,0;,"lli ,t- .: c'' -/'"' - , '' ''APPROVALS. K 1,'- ( . i,W, ,l \' '' >. /
j

'

, Med. IDx'r, , 18 ,.:_

, Med. Reviewer. , Med. Eeferee.

, ', ; '>::;fa[ISTO"Rlr,i;0PTCL'AIMS AND FORMER ACTION.


Last paid to._

,'- ,< ^' - ' Pensioned " - l i ' , . - . ,'^for;.


, u '.: -V"

QL_-..-4 -.-

-, 18.^.6, at $/^...-./.->-^rl_. under the Act of June 27, 1890,


I ^T^r^ I I 71 A

,; '-'.' ' tV ' ' f?' >,-i'. 7-"'. ' .,*: i.-^-.: .'

.Q^u^._Iu^k^.<m^^ 1 ?
--";>\
aZ,-/I
i A

r*. ' f

, 18-Q-Q, under 'Act of June 27, 1890, alleged


! i d A *

&\ OLX^vm. JQQLAX^VMxC^O' r^f^^^f^^^ '.'.". :/Vt*/ ^Declaration* filed , , , 18 ; alleged-

PRESENT CLAIM.
Declaration filea.:o5/i_..... ..._, isg.^., under general
"

(3125|

ORIGINAL INVALID CLAIM.


Rank, Company, Regiment *

Rates, $.

_.

_-_ ....per -month, commencing

Pensioned for..

Name,
P. O.,

Fee $

, Agent
'

to pay. , 18/?r

Articles filed _3-:.M&Z.:2..e^

Approved for

Approved for

,188

. Legal Reviewer.

, 188C/,

., Medical Reviewer.

Mustered

SS^/.^^A-r^-^U^fel^^:.......-., 18 18 6'd"

Discharged .^.-Mi^A^^Ar^.^.^^^

Declaration filed ^^^^S(^^S^^.....^!Z.^sR^. 18 CO.

.., Ex'r.

SIK:
Will information iswep;\at your earliest convenience, the questions enumerated below? for/future use, and it may be of great value to your family. \ 'i /Very respectfully, The

Commissioner,

No. 1.

Are you a married man?

If so, please state your wife's full name, and her maiden name. r< ///'^
"*\ tr>

Answer -J?fc^^2^Q^!^^^I<^^ Y^?^^^~/-^?^^^^ No. 2. When, where, and by whom were you married?

Answer: -

No. 3.

What record of marriage exists? Answer

No. 4.

Were you previously married? If so, please state the name of your former wife and the
(X I/ //

date and place of her death or divorce. Answer: -r^^p^^/vfe^^


\,&TtTJk*&S<Sl<**. ~t~'?l/^ (&^W'tfST^^.<%ll<^

.v^^>-^^^
No. 5., Have you 'any children living? birth. Answer: ^t2^U^L^^..a'L^^ If so, please state their names'and the dates of their

.... ...

Date of reply, V-i-&32::_/.-/0-2

, 189-^.
(Signature )

f '.:

A.
'

Declaration for Original Invalid^ensionJ[r; '"- A


' Cj " \s **"

^To be executed before a Court of Record .or some officer thereof having custody ofe

tuetttiottifl, personally appeared before me ^LLt&jgg^tTL of the, court of record, within and for the County ayd Statg aforesaid, resident,of the **-ffi^rrj
teof. he is the iawuieai^^^&tzzit&i^izrrf^

%s enrolled on^the.....^^. day of. ^Lz^jes^g:* ; 186..&, and served in Company....~Z%@/. of the : ./< Regiment of. .d^.<a^*:%f:- .^.J^k^^^; Commanded and was Discharged aw-. ^^,^2=^.<?^^2^rf!^t!!^..r t^^*^>^<^:. on the dL..'.'.....day of. ^^^^,. , 186.<L; that his personal description is as follows: Age .^Cd" years; height z.T. feet f."'.. inches; complexion....^z,^A ; hair....^.,^^.-:&.^I. .; eyes, .^^. That while a member of the organization aforesaid, inJM, service and in the line : in the State of. L^<!^^fe^r. , on or of his duty, at.... fcJ^...^^ur^5^2^^a^^t^t-^_^. about the JL&SJ&Lday of.
(Here state name or nature oW&isease, or the location of wound s (/ injury, "jf disabled by disease, state fuVLjc-fts causes ; Lf by wound or injury, the precise manner in which received.)

That he was treated in hospitals as follows:


(Here^ite the name^or numbers, and the localities of all hospitals in which treated, and the

............................... dates of treatment.)

That he

employed in the military or naval service otherwise than as stated above.

{Here state what other service, if any, was rendered, prior or subsequent to that stated above, and give the dates at which it began and ended.)

That -since leaving the service this applicant has resided in

ere state in detail the different places in which he has resided, from

That prior to his entruJmto the service above named he was a man of good, sound physical health, being, when enrolled, a ^jo/L^^k^au^L^. That he is now .~fci^Lxa_^^z_ disabled from obtaining his subsistence by manual labor by reason o/'the injury or disability, above described, received in the service of the United States; and he therefore makes this declaration for the purpose of < being placed on the invalid pension roll of the United States. * oittfe .with full power of substitution, MILO B. STEVENS & CO., of ' ^..L^Qllhis true and lawful Attorneys to prosecute his claim. That he has .......^.received ^2^i^.^3^. ....applied for a gensjon. That his Postoffice Address County ofV "','~; *

'Attest: --/I Z3L

Claimant's Signature :.J Jr 'jfe^LLA..*^^/s


(SKE THE OTHER SIDE.)

>**t<x6St,

X7 C/

IFROM THE OTHER SIDE.)

.., residing , residing at .././. ^persons whom I certify^to be apparentlyyespectable and entitled to credit, and who being by me duly sworn, say they were present and saw x^/i-<z<Arf^ the claimant, sign his name (or make his mark) to the foregoing declaration; that they have &very reason to believe, from 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 his claim.
TWO WITNESSES TO X /f

to attH JjtoftSttiM before me, this..-. j day of< A. D. 1883..; and I hereby certify that the contents of the above declaration, &e., were fully made known and explained\$o the applicant and witnesses before swearing, including the words ,. , erased, and the words added; and that I have no interest, direct or indirect, in theprosecuti

, y>^

INVALID

A.

Claim for Pension.


ORIGINAL.
Ipplicant.
f .& J
.Co.
r

Enlisted I Discharged,
*t; .1
ir.f.

FILED BY

MILO B. STEVENS & CO.,


PENSION CLAI^I ATTORNEYS,

.V (Execute ana Return KO'l^u Copies.)


This form of fee agreement is prescribed by the Commissioner of Pensions and approved by the Secretary of the Interior, July 8, 1884, under the provisions of the Act of Congress approved July 4, 1884.

Power of Attorney and Articles of Agreement.


TO BE EXECUTED IN DUPLICTAE WITHOUT ADDITIONAL COST TO CLAIMANT.

iinora all men bg tl)csc pre0mts, That


tf

late of Company /...S-sj.., of the /.. Regiment Volunteers, in the war of the Rebellion, have made, constituted and appointed, and by these presents do make, constitute and appoint J. JME. CURTIS, of Washington, D. C., my true and lawful attorney, for me, aria kn/nay name, place, ajra stead, with full power of substitution and revocation, to prosecute my claim forLJ/^>..^^..f?^L pension hereby cancelling and revoking all previous powers of attorney, if any have heretofore been givenin this case. NOW THIS AGREEMENT WITNESSETH : That for and in consideration of services done and to be done in the premises, Thereby agree to allow my attorney, J. 1H. CURTIS, of Washington, D. C., the fee of TWENTY-FIVE DOLLARS, which shall include all amounts to be paid for any services in the furtherance of said claim; and said fee shall not be demanded by or payable to my said attorney, in whole or in part except in case of the granting of my pension by the Commissioner of Pensions; and then the same shall be paid to him in accordance with the provisions of Sections 4768 and 4769 of the Revised Statutes. ~
(Signature of Claimant.)

PosL-Oflieo uddress, giving street and No,, if in a city.) (Signatures of two witnesses w/io fitau write in-evcry case.)

State of..^.J-sidWr4s&s<^^

..County of
, A. D. 18j#., personally .., the above named, who, after having had read

Be ji,known, that o# this^ie/,..^.fel...:day of. .......r^^d^^^r.

over to mim in the hearing and presence of me two attesting -witnesses the contents of the foregoing power of attorney and articles of agreement, voluntarily signed and acknowledged the same to be his free act and deed.

f~
/

^p^=.(,u^. = .;

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..6L&*.S C-<-*>Wt^ L&x^'O Attorney's Acceptance.


S58r"Leave the following to be fflteampwytlie attorney. "8 And now, to wit, this . < . . / . day o f . . A ^ f l ^ k ^ , A. D. 188^-iccept the provisions contained in the foregoing articles of agreement, and will,$wie best of my ability, endeavor faithfully to represent the interact of the claimant in the premiie^T7T~ hereby certify that I have received from the claimawj/^lroove named the sum of'^2^2^?^*:-.'^'-and no more; nothing being for fee, and<^?^^fe^^'^'. being for postage and othe>7Bxpenses. And that these agreements have been executed in duplicate without additional cost to th^claimant, as required by law, in excess of the fee above named, I/Kaving made no charge therefor. Witness my hand the day and year above writtenV

District of Columbia, City of Washington, ss:


Personally came J. M. CURTIS, whom I know to be the person he represents himself to be, and who, having signed the above acceptance of agreement, ackjiowledged the same to be his free act and deed. ~, Witness my hand and seal this <&./.. //A^ / day Qi...--.>/I^/3^^!^!^, , 18^ ^"

[i, s.]

Commissioner's Approval,
APPROVED FOE
J. BX. CURTIS, of Washington, D. C., the recognized attorney.
Commissioner of Pensions.

DOLLARS, and payable to

(Execute and Return BOTH Copies.)


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CO

ARTICLES OF AGREEMENT

FILED BY
s

J. M. CURTIS,

Formerly Principal Examiner and, late Assistant Chief of Division in the U. S. Pension Bureau,)

JK"

Attorney at Law,

W A S H I N G T O N , D. C.

(Execute ana .eturii^3OTH Copies.) This form of fee agreement is prescribed by the Commissioner of Pensions and approved by the Secretary of the Interior, July 8, 1884, under the provisions of the Act of Congress approved July 4, 1884.

of Attorney and Articles of Agreement. LTED IN DUPLICTAE WITHOUT ADDITIONAL COST Tg CLAIMANT.

late oftffffnpany.......~/...-^....; of the..............................Regiment Volunteers, in the war of the Rebellion, have made, constituted and appointed, and by these presents do make, constitute and appoint J^ 1ML CUR.TIS, of Washington, D. G., my true and lawful attorney, for me, e, place, jmd stead, with full power of substitution and revocation, to prosecute my claim pension hereby cancelling and revoking all previous powers of attorney, if any have heretofore beeu givenin this case. NOW THIS AGREEMENT W.ITNESSETH : That for and in consideration of services done and to be done iu the premises, I hereby agree to allow my attorney, J. IVE. CURTIS, of Washington, D. G., the fee of TWENTY-FIVE DOLLARS, which shall include all amounts to be paid for any services in the furtherance of said claim ; and said fee shall not be demanded by or payable to my said attorney, in whole or in part except in case of the granting of my pension by the Commissioner of Pensions; and then the same shall be paid to him in accordance with the provisions of Sections 4768 and2i769 of the Revised Statutes.

tico address, giving .struct and No., if in a oily.)


(Signatures of twtLwiLiuisses rflio'eau write-iiTevery ease.)

_l

State

....... County o / . . - ^......................,ss:


, the above named, who, after having had read

Be it known, that n t h i t h e .... w.^...tr::day of..........<^2"^^_.................., A. D. 18^3, personally


over toy him in the hearing and presence of thjs two attesting witnesses the contents of the foregoing power of attorney and articles of agreement, voluntarily signed and acknowledged the same to be his free act and deed.

L. S.]

Attorney's Acceptance.
the following to ba'fllJSlfcjm_t)y the attorney. "&. And now, to wit, this.........&*:....-..............day o f V x d x i r ^ d ^.............., A. D. ISj^V'r'I accept the provisions contained in the foregoing articles of agreement, and will, t^uie best of my almity, endeavor faithfully to represent the interest^ of the claimant in the premwjj!y^l"f"~ hereby certify that I have received from the claiman^iyabove named the sum of ^J^U^Lf^.,.^.. and no more; nothing being for fee, aud^^^ui?***...^.................being for postage and othep^expenses. And that these agreements have been executed inimplicate without additional cost to therolairaant, as required by law, in excess of the fee above named, I/waving made no charge therefor. Witness my hand the day and year above written.

District of Columbia, City of Washington, ss:


Personally came J. |RE, CU'R.XSS. whom I know to be the person he represents himself to be, and who, having signed the above acceptance of agreement^acknowledged the same to be his free act and deed. ^ Witness my hand and seal this .*&..!.. ..day

Al'PEOVED FOE

Commissioner's Approval.
.

.DOLLARS, and payable to

J. IVS. CUR.TIS. of Washington, D. G., the recognized attorney. Commissioner of Pensions.

NOTICE TO CLAIMANT.
This Contract Is Permissible Under the Law, but Not Compulsory, Read the following Copy ot the Statute.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled * * * * * * * SEC. 3. That section 4785 of the Revised Statutes is hereby re-enacted and amended so as to read as follows: " SEC. 4785. No agent or attorney or other person shall demand or receive any other compensation for his services in prosecuting a claim for pension or bounty-land than such as the Commissioner of Pensions shall direct to be paid to him, not exceeding $25; nor shall such agent, attorney, or other person demand or receive such compensation, in whole or in part, until such pension or bounty-land claim shall be allowed: Provided, That in all claims allowed since June 20, 1878, where it shall appear to the satisfaction of the Commissioner of Pensions that the fee of $10, or any part thereof, has not been paid, he shall cause the same to be deducted from the pension, and the pension agent to pay the same to the recognized attorney." SEC. 4. That section 4786 of the Revised Statutes is hereby amended so as to read as follows "SEC. 4786. The agent or attrney of record in the prosecution of the case may cause to be filed v-ltL the Commissioner of Pensions duplicate articles of agreement without additional cost to the claimant, setting forth the fee agreed upon by the parties, which agreement shall be executed in the presence of and certified by some officer competent to administer oaths. In all cases where application is made for pension or bounty-land, and no agreement is filed with the Commissioner as herein provided, the fee shall be $ 10 and no more. And such articles of agreement as may hereafter be filed with the Commissioner of Pensions are not authorized, nor will they be recognized except in claims for original pensions, claims for increase of pension on account of a new disability, in claims for restoration where a pensioner's name has been or may hereafter be dropped from the pension rolls on testimony taken by a special examiner, showing that the disability or cause of death, on account of which the pension was allowed, did not originate in the line of duty, and in cases of dependent relatives whose names have been or may hereafter be dropped from the rolls on like testimony, upon the ground of non-dependence, and in such other cases of difficulty and trouble as the Commissioner of Pensions may see fit to recognize them ; Provided, That no greater fee than $ 10 shall be demanded, received, or allowed in any claim for pension or bounty-land granted by special act of Congress, nor in any claim for increase of pension on account of the increase of the disability for which the pension had been allowed : And provided further, That no fee shall be demanded, received, or allowed in any claim for arrears of pension or arrears of increase of pension allowed by any act of Congress passed subsequent to the date of the allowance of the original claims in which such arrears of pension or of increase of pension may be allowed." And if in the adjudication of any claim for pension in which such artide's of agreement have been or may "' - be " -1 v the claimant .had,1 prior . to. the 1. - . - , 'SVn thereof, paid to the attorney hereafter 1 -- filed3 it"shall11appear that - ^ - i any sum for his services in such claim, and the amount so.paitUis ated therein, then every such claim shall be adjudicated in the same manner as though no articles it had been filed, deducting from the fee of $10 allowed by law such sum as claimant shall'sho: ,, '..paid to his said attorney. Any agent or attorney or other person instrumental in prosec I1 jjaim for pension or bountyland who shall directly or indirectly contract for, demand, or r e c e e reta'iji any greater compensation for his services or instrumentality in prosecuting a claim for pensioner bounty-land than is herein provided, or for payment thereof at any other time or in any other manner than is herein provided, or who shall wrongfully withhold from a pensioner or claimant the whole or .any part of the pension or claim allowed and due such pensioner <or claimant, or the land-warrant issued to any such claimant, shall be deemed guilty of a misdemeanor, and upon conviction thereof shall for every such offense be fined not exceeding $500, or imprisoned at hard labor not, exceeding two years, or ,.bj>tih,, in the discretion of the court. APPROVED JULY 4, 1884.

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'Comrade.

Additional Evidence.
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FILED BY

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. Stevens & Oo., War Claim Attorneys,

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ORIGIN OF DISABILITY.
NOTE.Tills affidavit must be executed by a Commissioned Officer, or First Sergeant, if possible; or if not possible to secu) timony ol such, then two of the soldier's comrad es should testify.

/)

/"I " r^/

A. D. 18/'y? personally appeared before me a

.'

in and ^f,- the aforesaid County/duly authorized to administer oaths for aged (g /^Cyears, a resident of ^J---who being in the County ol...l^t^l^/SUd^tO^i^^r.. and Sta

";jl -,'!, "i., 'duly sworn accruing to law, states that he is '."' ',>">,( ' '.''**Qf JO' _ "who belonged-toGo'.* :^,.:..._......s2......Kegimen't'of

. a n d w h o i n t h e lijfe o f duty

in the State o f i Z & r - ^ . ,


beoome

did, on or about the

disabled in the following manner, viz:

[Hero stateJiow, when and where tie wound or injury was received, tiVe part bitnebb'uywou^^^

[If sicsnetis, BtateAvhen, v^Jiere tol under whal^ou-oumstances contracted, w^at causecyt,, the name or nature of tbe-gte causect wa^ououmsances of

. ..0!.^i^.^i(^^

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c. .6tf&a>.t<.,, *^ %,(xy. . . . c&. (. (, \. . . .<&. . . .
. /
yfrn'iv niLy.

-z^u, .^t-^^. . . &

. . *' **
L V^ ^

4^1 2i*^^ /^^Here stattwlietlier afflarit was wltii tiiw command ~


* '" f' ^*^ v "^w* . n te!fowi* ~ j f ^ /? /t '' / i

^*^...?....&c_

j^ 4-aL# jrisySCVmrt'\. (LflS t/~~lsl/l~~ *^L.isls\-^..A /Z'Vt-C, JV^JW^eriAf ^if^t^tffk^At7} ^f ,&t^7T^:<"~ 5 time tile soldier contracted ni& disability, or whether his knowledge was otnorvvise obtained. All tue facts known to affiant riaativo ofthe soloter's me^ilcattreatmeiiij 101 lub ukabiuliy wnue m the bervicj3il)3ftt3,UKStoted, giving rame and place, H possible.}
' ^,

'*^<.. 6*^1.({... iQ&Miif^^j^ .

And deponent further states that he is well acquainted ivith said soldier, having known, him for at least fljf Q. years and further, that his knowledge oijtlie facts above Stated is derived from said acquaintance and from havingserved . a s ^ ^ ^ a ^ A o f Company ....#\. of .the ........,/ij........................Regt of .2 SpL.......day of L&sC ....................186'J to the.........cC.3^"'.....................day oi that he is totally disinterested in this cjajm. / /) / Post office-address of affiant i ^ s U ^ ^ ......
&

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from the 186^-and

(If affiant sign liy mark, two persons who can write sign here.)

Sworn to apd subscribed before me^by the above-named affiant this /../.._ and I certify that I read said affidavit to said affiant, including the words erased; and the words

day of , addid

and acquainted him ;ffith,4J&j&ate!p&bf]%Ml^^^ certify, that'I-aia-iirno'wise'iHtWested in said case, nor am I concerned in-its-prosecution; and that said affiant is personally know to me_aniLthat he is a credible person. C/4sJ A
sA ^fflliia-1 Signature. j_tZll^i ('Official Character.) ~

":V7. State, do certify

.. Clerk of the Court in and for aforesaid County and , Esq., who hath signed his name to the

foregoing declaration andvaffidavit was at the'time^-oi so doing &.U^^^^^^^^,....>^,...^f^z^, df~Z&^cJ(Ljei'n and for said County .and State, duly commissioned and swonr; that all his official acts are entitled to full faith and credit, and that his signature thereto is genuine. Witness my hand and seal of office, this [L. S.] Clerk of the

NOTICE.This should be sworn to before a CLERK OF COURT, NOTARY PUBLIC, or JUSTICE OF THE PEACE. Itbetorea NOTARY (tvithout a sealjor JUSTICE, the CLERK OF COURT must afld Ms certificate of official character hereon, and not on a separate slip of paper unless a general certificate of official character has already been fllefl in the Department at Washington.

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AFFIDAVIT FOR COMMISSIONED OFFICER OR CQMRABfrBfrL


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CSKEE1:

COUNTY OF
In the Pension Claim of
(.flame ol Claimant.)

came before me, and for aforesaid County and State


w

(Name o'f Affiint.)

..Regiment of , and now a resident of... State of.

zy J^L*6t^^X&iLJi*&&iidLisssasi*~~^
. ~
' ' ', * xT . / <

(Give efiyVVfllage or Town; il in'the city, give name ol street ana nnmber ol house,)

well known to me to be

JY ' reputable and entitled to credit, and who, being duly sworn, declares in;the aforesaid xase,,s,follow's: . i k , v That....
(Name of Claimant.)

in Company

/ X

of -the,
. V'

..Regiment of...- *...:zx.z.fai.?.fr.~....^.Voluiiteefs of the war of 1861, while


*'

in,the military service of tjhei|Jmted"States, in' the-.line of' his' duty, and without'fault or'improper conduct of his, / on oi- about the <^Lis!E~*!.day of....~::^.^..^..^^^rJ, 186.^:...,
^f^^.^...-J^.^JC^.-&l^^^......'j^

,,,

,,,*r^.-^-- -".,,/

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AND "i'FURTHER CERTIFY j^rr^rralslnl^


'.*'*"'' ' *

.i^^^.......^^j!^saa..:~^^^---..^

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statement from"

(State HOW you know these facts to be true. If present, in command or otherwise, when the disability was incurred, so state.) -^ ' ^

&.&&*&.

J&ii,^.-...<&&&t^

e Affiant signs by X mar. x. (Name of one witness.) /I


* fcxl^f-t X-- *K Irf"" ^2r ..

-- v i ^fffmi^,

ST sign here as witnesses to Snoh signature.)

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(Affiant sign here.) j(.S

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**'"i <Natoi of otticir witneBB.^

(SEE THE OTHEE SIDE.)

ssioned Offkep oigComrade. '

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(Name o
.) ' . / /

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FILED BY

. Stevens & Co. , War Claim Attorneys,

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ORIGIN OF DISABILITY.
NOTE.This affidavit must be executed by a: Commissioned Officer, or Hrst Sergeant, if possible; or if not possible to seciiS^tne tf"J'fiMp timony of such, then two of the soldier's comrades should testify.

,<> $$&

A. D. 18/Wv personally appeared before me a

s7 J ^ ..ifi and for the aforesaid County, duly authorized to administer oaths
aged (pyearsa resident of. in the County of /^^^t^t^^^*--*^., and State of Ok^C^-^r^-^^^-^-^^Crt^,... .svho being

Q duly sworn according to law, states that he is acquainted with ^l^AjL^V^^-t^


in the State of

who belonged to Co. . /..Ql.iS..'. .'../ <2....". Regiment of ' at or near /&r^J^LjL^t^s&Cj day oiyQ^/L4s,

Vols. and who in the ljSle of duty ^ . did, on or about the

186^fbecome disabled in the following manner, viz:

[Here state how, when and where the wound or injury was received, the part b'i'the"bbu'y wounded or "lujured,"aJi5""ail"t:bo~ciroumstai"ces attending^.

..."_'

. .

...;_.

; _ . . ^-,

jJi^TCKness, starce wneAws^nerve ana unaer w"^c;^^mn^ajp,^^^cxi%tea^ ^'^affected liim,] ^ *

or nature ol tne sickness, ana no wit ^r-

/jL#&<^&*&^.)..^-G
(fa/fad.-^?...^f/3C_v^*-At<*-<.v/'^c^'.^.v^?.ievfLfr.Hj, Jr..$t(.sio~.G^-jfaz.dL^L-A<K<<V...t&tffiAt,...

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& &iL^ZLJJ^^
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That the facts'stated'are'personally known to the affiant "by reason o i L / <txv _ - ^ _ . x^v y v ^^^^^ - -^ _ /I fflere state whether afllant was with the command
M~ISJ^:6'.^K'.~ ,^^t*iu^t^,vv f

atfthe time the-SOldier coirtractea his disability, or wn'ether his Rnswleflge was otfifrsvise^otaiiiect. JB1 tj^e f aots Sn^nto afflajiti-olative

V^^V.Jt't-^ If jst'tsl/is is*s\

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^ry ^^,^^fy. .^,^.

-v^.T^.::

Cii^"J^t^_-

Asll^' ^L^lSj'L

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. . < mgStoal ' ^ ~ s ' . . of the . soldier's > f - trcacmeut 101- lus ulsaijj^ity wmie in tue service should be stated, giving timerana place, if possible.]

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CLAIM OF

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AFFIDAVIT OF
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ORIGI1T of DISABILITY
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FILED BY
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J. M. CURTIS,
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(Formerly Principal Examiner and late Assistant Chief of Division in the TJ. S. Pension Bureau.)
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WASHINGTON, D. C.

P g g ?ff SO

PHYSICIAN'S'AFFIDAVIT.

PROOF OF PHYSICAL DISABILITY.Act of June 27, 1890.


TAKE NOTICE.The affidavit should, if possible, be in the handwriting of the affiant; the marginal instructions must be carefully observed before writing out the statement. -All the facts in possession of affiantas to the origin and continuance of the disability should be fully set forth, and the dates of treatment should be specifically given.

0tote of
In the Pension Claim No.

, 00:

(Company and regiment of service, if in the army; or vessel and rank if in the navy.) Personally came before me, a - .-^.^Q^^tArt^^ttfCounty and Bt&tQ ---f^^-X..(^..^f^..rj^f^.^C^:^^rwhose Post Office address iswell known to me to be reputable and entitled to credit, and who, being duly sworn, declares in relation to aforesaid case as follows: That he is a Practicing Physician, and that he has been acquainted with said soldier for about ~^Lj~______years, and that (Here embody all the facts kndwn to the affiant in accordance with the marginal instructions. No erasures or interlineations will be permitted unless the magistrate certifies in his jurat that they were made before executing the paper. ^/^^fa^Cff.,_^L~. a citizen of~ in and for the aforesaid

NOTES.
The Physician's

Affidavit must show the following; facts: 1st. A complete diagnosis of the disabilities u p o n which the claim for p e n s i o n is based, and the period during which he treated him. 3d, That the aol: dier is suffering at p r e s e n t from a mental or physical disability of a permanent character not the result of his own vici.ous habits which incapacitates him from t h e performance of manual labor in such a degree as to render him unable to earn a support. The degree or extent he has been disabled since the filing of his application should be plainly stated.

He further declares that lie h.is been a practitioner of medicine for interest, either direct or indirect, in the prosecution of this claim. -,

e~4~,?.

years, and that he has no

(Affiant's Signature. Give rank and service, if in the army )

Sworn to and subscribed before me this

.i/

day of

^..^^.^t^^Za^r.f^^^,,

A. D.

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, including the words erased, and the words ; prosecution of this claim.

added; and that I have no interest, direct or indirect, in the

[L. S.]

I,, and State, do certify that foregoing declaration and affidavit was at the time of so doing
> . \\ \

Clerk of the County"Court in and for aforesaid County , Esq., who has signed his name to the ..... in and

for said County and State, duly commissioned' am\worn ; that all his official acts are entitled to full faith and credit, and that his signature thereunto is genuikt> Witness my hand and seal <
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[L. S.j

Clerk of the.~

NOTE.This can be executed before any officer authorized to administer oaths for general purposes. 11 such uses a seal, certificate of Clerk of Court is not necessary. If no seal is used, then such certificate must be attached.

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PHYSICIAN'S- AFFIDAVIT.

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PROOF OF PHYSICAL DISABILITY.Act of June 27, 1890. I

TAKE NOTICE.The affidavit should, if possible, be i'n the handwriting of the affiant; the marginal instructions must be carefully observed before writing out the statement. All the facts in possession of affiant as to the origin and continuance of the disability should be fully set forth, and the dates of treatment should be specifically given.

0late of
lateof
(Company and regiment of service, if in the army; or vessel and rank if in the navy.) Personally came before me, a ...-...-!===^>^<K^S4>^^ County and State ..'?Si^y^fJK/...?^.'f^.f^*r^twhose Post Office address iswell known to me to be reputable and entitled to credit, and who, being duly sworn, declares in relation to aforesaid case as follows: That he is a Practicing Physician, and that he has been acquainted with said soldier for about .^years, and that a citizen of-~" """ in ana for the aforesaid

(Here embody all the facts known to the affiant in accordance with the marginal instructions. No erasures or interlineations will be permitted

unless the magistrate certifies in bis tarat that they were made before executing the paper.

NOTES.
The Physician's Affidavit must sho"w the fo 1 lowing facts:

1st. A complete diagnosis of the disabilities u p o n which the claim for p e n s i o n i s based, and the period during which he treated him. 2d. That the soldier is suffering at p r e s e n t from a mental or physical disability of a permanent character not the result of his own v i c i o u s habits which incapacitates him from th e performance of manual labor in such a degree as to render him unable to earn a support. The degree or extent he has been disabled since the filing of his application should be plainly stated.

He further declares tliat ho lias been a practitioner of medicine for interest, either direct or indirect, iu the prosecution of this claim.

years, and that he has no

(Affljints Signature. Give rank and service, if in the army >

Sworn to and subscribed before me this

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A. D. 18 /S that the

and I hereby certify that the affiant is a practicing physician in good professional standing;

contents of the above declaration, &c., were fully made known to him before swearing, including the words erased, and the words added; and that I have no interest, direct or indirect, in the prosecution of this claim.

[L. S.i I,

"

'

(Official Character.)

Clerk of the County Court in and for aforesaid County ----, Esq., who has signed his name to the in and entitled to full faith and credit,

and State, do certify that

foregoing declaration and affidavit was at the time of so doing- for said County and State, duly commissioned and .sworn ; that all his offij and that his signature thereunto is genuine. Witness my hand and seal of office, this

[L. S.j

Clerk of the

NOTE.This can be executed before any officer authorized to administer oaths for general purposes. ,11 such olli uses a seal, certificate of Clerk of Court is not necessary. If no seal is used, then such certificate must be attached.

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