&.;•Tt«/

ElMBURSEMEPIT

A.CT OF JULY 14, 1862. . ;

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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, placep

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.)

Mint lie hereby fippoints, with ful 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 certify 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 IJJJTI liirc HBHM (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 that

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

[if AJflants sign by mark, two persons who can write si^n hero,] [Signature of Amanis.J

Sworn to and subscribed before me this ±£ day of . ..... ... r T /f '* '. A. D. :

and I hereby certify that the contents of the above declaration, (fee., were fully made known and explained to the

applicant and witnesses before swearing, including 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 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 Co'unty and State, duly commissioned and sworn; that all his official acts are entitled to full faith and credit, and

chat Ms signature thereunto is genuine.

Witness my hand and seal of office, this-. day of , 188 .

[L. S.] Clerk of the...

NOTE.—This should be sworn to before a CLERK OF COURT, NOTARY PUBLIC, or JUSTICE OF THE PEACE.If before a JUSTIpE or NOTARY, then CLERK OF COUNTY COURT must add his certificate of character bereon, andnot on a separate slip ol paper.

RH

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\

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 ofA. D. one thousand eight hundred 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^ official seal of said Court,

' y e a r s , a resident o f

County of -<3rr?^OAfe^=fe? in the State of

who, being duly sworn according to law, declares that he is

who enlisted in the service of the United States at '*3Lfa-_ <^JsS^t/is±£>_ .on

day o f _ . _._gp?^^<^u«-4*/ 186/ , as a x.'^jfJC.^fM:-'. '.'_-' in the Company commanded by

.^^k^S^.'^.Aife^^^ , kiiownj^Company^^/jL^—^in Jhe._^,_^^^^rI \s /ft / £~ '

Roffimcu't of,(JyW../Sxi4xfc^A-. . . _ . , . , „ , , , . , . - -_ , _ / s^-Cr*es^-*-~*~<'

-*-- volunteers, in the war for the suppression of the Rebellion in

certain States of the Union , and far the maintenance of the Federal Government, 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 certificate of disability, 'which is filed in the Pension Bureau at Washington, and is to be deemed

and treated as part hereof, 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 duty, he received the following wounds or disability, to-wit: OnAthe

day of , -O-I^L __ . . , A. D. ** '&*-*isjk.<StTTt<*it - <2^x*jrrs-v^

j t ~ / " A— r ,/~ ' / /J?f^-^^ t7

^^y-

*3&lJi&UjL^-^^-&tts&J&^^ &CsXtS>~M^e^. --£?^L<f>~*^*(^

I A t , •If i in ' ,t.^jAFf±~!?^--<»b?Cl<4<3^1sZto^r&

, - - . - , -t^r^\~£<_^>iA*4*~£is/ 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 iaofdress is ^£§^^£^7 ^ __UountyofXT" f ^^ A^zJ^S i// ^State of _______ O?TM<- o ^^ -t T. _______ ; and this applicant solemnly, swears that he has at all times borne and will bear

true faith, allegiance, and loyalty to the Constitution and Government of the United States, against all enemies, whether

domestic or foreign. /•,. .a

And I, the said applicant, do hereby constitute and make HEQUEMBOURG fttetL, of St. Louis, Missouri,

my Attorneys in fact and irrevocably, for me, and in my name, to prosecute my said claini and to receive and receipt for the

Certificate 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.

WITNBS

THE'FOREGOING DECLARATION AND POWER OF ATTORNEY 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 written,

-

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BOUB

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% 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.347479Hannah^Sulliyai£EpARTMENT QF THEratriclc SullivanC 11 Mo. Inf. BUREAU OF P E N S I O N S

WASHINGTON Deo.14,1930.

Mr.Robert S.Sullivan3768 IcCausland Ave.St.Louis,Mo.

Sir;

Relative to your claim for reimbureement in theabove-cited case,you are advised that the enclosedcertificate should be signed by Doctors R.S.Hill andS.H.Reynolds and Helen Sullivan and returned tothis Bureau.

Very respectfully,

«»# Commissioner.JGB WDC.

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pIP ; '*^^^'^^-Mf^in

^Halte

Very

» P.Billto

W150,

MEMORANDUM

Maplewood,

S. H. REYNOLDS, B. S., M. D.

191UD

For Professional Services To.

Received Payment,

BILLS RENDERED MONTHLY

Form P-26

-RICHMOND HEIGHTSST. LOUIS CO., MO..J

HOURS:To 9 A. M. 12-2 and 6-8 P. M,

KINLOCH, MARSHALL 268-RBELL, 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*7f*g>,. og

" ^"2/' -9^., p-C» /»^& ih 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, IvOi'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 /

'MM this (Ing lH'fyi/lropw',il lff'oni,ltiw jrul-f- IK:-

Mm*-.

S T L O U I S t] 02 4 7 •'; 7 D M A Y

3500 c i . i v ; ; :;r,:

f

'W I D

Very respectfully,

'<&>&&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: , _____ /:

AMOUNTS CLAIMED.

Physicians' bills _-- - --

Medicine _ -- v -

Board

Nursing and care ~ ~ _ -- --

Rent -

Living expenses for pensioner

Undertaker's bill -~ .

Liverv

OTHER EXPENSES.

-~^y~^

TOTALS ./ _ ..../

$

CHARGESAPPROVED.

f7$ SO

'**-

-? i-S-

^^3

-*-*

^>~<>

DEDUCTIONS.

State aid

Assets

Insurance

TOTAL

$

SUMMARY.

Charges approved

Deductions

Amount approved

X"'

—

^^^ -*-*

f

Approved for

tExaminer, ]{/ Reviewer.

Courtney, C. Alclrlch,Sec. & Trens.

Laura A. Parker,President.

Orrln B. Laug,Vice President.

WEBSTER GROVESBell, Webster 205

MAPLEWOOIJBell, 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° —

£> 02 -

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 from, date of last payment to date .t

pensioner's death in this case ijs 737777: and no

sum is available for reimbursement.

I hereby certify that I hold

•responsible for the payment of any portion of the accrued pension

to which I may be entitled for services rendered, supplies fur-

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, t o . )

ST. AUGUSTINE'S CHURCH,2568': 1EBEKT STREET,

Rev, H. HUKESTEIN, /

ff

(Attorney,k St..

(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 P R O V A L S:

( . '- , 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

<2fFormer 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

APPROVED

Claimant,

P. 0.,

County,

State,

Attorney,

Rate, <

INVALID PENSION.

Rank,

Company,

•/ yRegiment, 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

Company,

Regiment,

_/•*"'

'

Kate, per month, commencing

Submitted ftr (^L^L^L-.jLP.i. , 18

^_Approved for . . £ .1 :^?^^^

* //'..r....t 18<?*f. Last paid to ..... -., at

Original declaration filed

/ /^

/ed from .... $:.&&&%'--.£$-•--•, 18W,Arrears allowed

Declaratipn filed ....j£y..Z.£L~Y—t. ..., 18//

f ,

(7280—75,000.)

'AR Q!F THE REBELLION.i • :. Cf 0 '

INVALID PENSION—ORIGINAL.

Eank, . . r ^

Regiment, .< ...o....5:

1 SERVICE.

,18 , in

Material evidence filed since July 8, 1870.

Discharged (taken from

Eate of pension, $ .per month, from

Declaration filed... , alleging dicdbility

THE ADJUTANT GENERAL REPORTS—

Enlisted,.. ,18 Mustered,...

Transferred to V. R. 0.,.. , 18 ; cause,..

Discharged,

RoU for

j covering date of alleged disability, 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 INVALID 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 human skeleton and figure upon the back of thiscertificate, and they should be used whenever it is possible to indicate precisely the location of a disease orinjury, 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 nameof the absence, must be indorsed upon each certificate.

Insert eharacterfand number ofclaim.

Name a iu.l rankof claimant'.

Q^panv . . ^ .. .... ^-Cluinmiit 'a poaty

^3 address. ^r - - - ^f^y ' (Date of examination.)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 i a a -bility.

e receives a pension of——_—= - . r~/?-- _ dollars per month.if not, erase the ^y \* 4& >y /~^jf^'~7whole 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'er jff^r^^T^ ^ sz~^^Z/^/3*£/^—...»_SBT,__ ^C_U ____-_ j< . '

Ki^iis, u i t 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 that *^~iho duty of theSui'geon is to

portionato de-

A c . , through

•yard to dollarsand ccnte, and , -->v>£" sto make such a/^Z S^T^C-full particulardescription aswill afford to-this Office the

ion antl action

ta lftting-

Kate for eae/ tau^ of dUa-

the word note li o u 1 d b eerased uud thereason for theerasure 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^itsD &? £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._J Here state -whether for .ojiginaj, increase, jestoiatioii, or renewaljOr 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—in.) rf

• Attention is invited to the. outlines of the human skeleton and figure upon the back of thiscertificate, and they should be used whenever it is possible to indicate precisely the location of a disease orinjury, 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 nameof the absentee, must be indorsed upon each certificate.

Insert character!and number ofchiim.

2Jame and rankof claimant.

Cluiniiuit 'scilice address.

-— Pension Claim No..

(Date of examination.)

We hereby certify that in compliance with the requirements of the law* we have carefully examined

this applic£urfO?horstates that h^ js__suffering from-^he following disabjjjg?, incurred in the servics, viz:

Cause of (Haa-bllity.

if not, erase thewhole line.

receives a pension of—_«^ _?~i5l. dollars per month.

Pulse rate per minute, Jf..^...-, respiration,—f^.^i...; temperature,.-^??—-—) height, -.y.

....^f-. inches; weight,— £0^^?....pounds; a.ge,—-^/&2—years. /j f^~^y

kesthe following s>^ement,upcm which he bases his claim for y&r?S^&^ ^^^^^

4 sn examination we fina thp following obeowft-eoriBiJious: .

id dollarsand ccnfa, andto make tmcli afull particulardescription

_ _ _

Bate for eachc»«o of <!«,

"vlckm" Miit?the word no(s h o u 1 '.1 b aerased and thereason for thoerasure 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 that^itias

not been prolonged or aggravated by vlpipus habits. He is, in our opinion, entijjed to a_t<2 .^fc?--'?

rating for the disability^aused M- — .1' that'caused

a seer

"See the back.r,\e state whether for original, inciease, jestoration, or renewal, or for a re-rating.

N. B.- -Always forward a certificate of examination whether a disability is found to exist or not.

(6127—100,000.)

.

SingLwill erfoot 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. Write }ou, PcSi-fffiee adcjress plainly and in full.

PROVIDED 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 thephysical and rational signs and a statement of all the structural changes. [Extract from Section 4, Act ofCongress approved July $15, '

(3-

EXAMINING SURGEON'S CERTIFICATEIN THE CASE OF AN APPLICANT FOR INCREASE OF PENSION.

G SDBGEON'S AJP»BKSS

t office,....

"/

(ir^^rfy^fr...^^^^/^

*^..&r£4i& ;

-13 g{ fc* sa?

lilt

S P^O^*»

Jttaaina /iom me condition ana fMtoi-u txf we etaitnantj it it) .jfct^y.. opinion

CM inoetHeaf on tfne deivcce CM oiacfneiZj <&nc& tnat it ii net aaaictvafeef oi• f ff

vicious navitA. /?L22y

/{/net tne cWavfaitM CM cweve ctedett&eat,.to. qntittA mim to a ..JTK^^f-'' s f "a ~£f~irJ~/'^ ?

&s £"**'!/ GEji— 's^^^> C^%£ / 5^ Examining Surgeon.

The Surgeon will forward his report of examination direct to the Pension Office wlwther the pensioner is thought to beentitled to increase or not.

•*» >ra<<

(3-Hfi;)

EXAMINING SURGEON'S CERTIFICATEIN THE CASE OF AN APPLICANT FOR INCREASE OF PENSION,

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 Officeentitled to increase or not.

Examining Surgeon,

pensioner is thought lo be

•38

3 l l f i : )

EXAMINING SURGEON'S CERTIFICATEIN THE CASE OF AN APPLICANT FOR INCREASE OF PENSION,

EXAMINING SUR«BON'S>j)DBESS:

Post office,

County, -"/

State,

Company,

Regiment,

State,Date of examination, _______ f r < _ , , '188

Thatthepresentrating is un-justly low, orthat there hasb e e n ac tua lincrease of thedisability.

^Particular de-scription.

ing for onetwo reasons—that the pres-ent rating isunjustly low,orthat the disa-bility has real-ly incIn eit!the reasons forchanging the

' present ratingishouldbeclear-

afullstatementof the physicaland rationalsigns.

•^ff^-^ e^ <jf^^-^^:^-^^z,^t.

7^^.p . ^^^^k^ . ^ .-v^ .... . ^^-^^ . ^^-

^fer-<?t£-:z££?&&<l£*!6£2 &£:--x:;.-..jtz>£^:.

sS a f e g-^.i••a?*

EH-««

fac/aina /iom me concutiom ana /Mfoiu of me

VCM inowkieat on tne deifies M ctai'mea, a•viciatt;) navifa.

cm a&ove

it M not aaaiavafoa

The Surgeon will forward his report of examination direct to the Pension Officeentitled to increase or not.

Examining Surgeon.pensioner is thought to be

5

'° SURGEON'S CERTIFICATE

D«fe of Examination i

/? ^

Examining Surgeon,

Post Office, -,-

County,

State, ;_..—.__..

P, S.—Write your Post Office address plain and in full,

|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 beforwarded, 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^jLt ___ /,j._jl., ____ 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£^--^~~-~-^~-ijf-' » State of

, who, being duly sworn according to law, makes the following declaration in order

to obtain reimbursement from the aacrued-jension 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. joZ-^.->fcl-j(!.^~-/~----i. °n Account of the service of....—l—^^f/jK^A-------^ 1 u. ,—'-."jf.-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, ijjyn the iNftvy.)That pension was last paid t^.AM4f^^A.sM^^^£f^£^i-.-^.., .481' <i£&*!~^-€f / Y Q^- & >

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 adjustment 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«jK>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 thedecree 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 **

•"" ~ " " ; y7. 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 incase of any item of expense noted.

(Each charge entered below should be supported by an itemized bill of the person who rendered the service or furnishedsiny supplies for which reimbursement is demanded, and should show, over his signature, by whom paid, or who is heldresponsible for payment, and contain the name of the pensioner for whom the expense was incurred or service rendered.)

STATE WHETHER PAIDOR UNPAID.

Physician .

Medicine

Nursing and care

Undertaker

Livery

Cemetery

Other 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 —iji-'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 _._ „'.

STATEMENT OF ATTENDING PHYSICIANS.

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 ...... _____ _•_

jDoes 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 adjusting this claim for 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 sro f»!§.B'S*t° B tt'&l?'8:l w ^ SS 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 whethera certificate therefor 'shall issue prior or subsequent to the death of such person, shall, in the case of a person pensioned, orapplying for pension, on account of his disabilities or service, be paid, first, to his widow; second, if there is no widow, to hischild or children under the age of sixteen years at his death; third, in a case of a widow, to her minor Children under the ageof sixteen years at her death. Such accrued pension shall not be considered a partof the assets of the estate of such deceasedperson nor be liable for the payment of the debts of said estate in any case whatsoever, but shall inure to the sole and exclusivebenefit of the widow or children. And if no widow or child survive such pensioner, and in the case of his last surviving childwho was'BUchT'minar at hjs death, and^in case of a dependent mother, father, sister, or brother, no payment whatsoever of their

^ttWrtiTOof 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 orminor 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 sourcesucn payment was received. If unpaid, the parties to whom said bills are due should note on each bill, over theirsignatures, that they hold the claimant responsible for the payment. If the bill be for medical treatment it must showthe dates of visits or treatment and the charge for each. A bill for nursing and care must show the dates betweenwhich the services were rendered, and the rate per day or week. The bill of the undertaker must be itemized, andshow 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—1672

£2g^«=£3SL..-., 00:

v. 188 0; personally appeared before meON 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, andnot on a separate slip of paper.

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.S6S-PH YS'J.01 &.N8 , OUT. THESE ,

Certificate must be 'fully and;accurately filled out, or,it will not be received and signed,°®«

of Deceased: ^..^...^...

Years, Months,

Cross ouf the words not required.

Place of Birth .

Place of Death .ii££...**f&*..<f...t.

Date of Death*.

Cause of Death..

•I CERTIFY that I attended the person above named in.,

the disease stated, on the date above named.

last illness, who died of

M. D.

| Place of Burial^.....:.

Undertaker.

i OFFICE HEALTH DEPARTMENT,

St. Louis, Mo., 188

I CEETIE7;:that"I have examined this Certificate, and find it to accord with the requirements of the City

Ordinances and Charter and the Mules of the Health Department.

Health Commissioner.

Clerk tt Eaalth Commissioner and Boird it Health.

vided by Ordinance No.110J329.

receiving Burial Certificates without the signature of/he Commissioner or his Cleric, will subject themselves to a.fine, as pr

* In filling out thevabove Certificate -Physicians are e. ,ested to conform strictly to the Nomenclature printed on the back.

ir

.J

4N

1\J

sg<£ft

*K>

*n•S<»

"K>«3«SSiPs

6o.-S-:so-K>£8•i<.o

•K>**>

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>

1

NOMENclATOR^^fr-l^Mfe.'^X • .OLA-ss i.

SYMOT1C. "1

ORDER 1.— Miasmatic.

Diarrhcea

Dysentery

f Entero-Colitis

1 Erysipelas

' Group., ,

1 Diphtheria

Tonsilitis

Fever, Bilious

" Cerebro-Spinal....

" Congestive.

" Hectic

" I ittent '

" Eemittent

" Scarlet

" Typhoid

" Typhus

Measles

Pyaemia

Septicaemia

Toxaemia

\a

Variola

• Varioloid

Whooping Cough

ORDER 2. — Enthetic or Inocu-lated.

Malignant Pustule

Alcoholism j ManKrpotue:

Inanition. ;

Purpura Itemorrhagica

'i* ORDER 4;— Bcfrosttie.

Tsenia

Vermes

' j <' 'Vat

"\» QmeA f.—biatlietic." A < r-~~^Anaemia , t. .T^Ti

" Breast -iVlAJ}

'* Intestines

" Ovary,

-

ORDER 2,— Tubercular.

Abscess Lumbar

Gangrene

Hydrocephalus

" (Chronic)

Phthisis Pulmo.mUis

Scrofula

Tabes Mesenterica

TubeicularBionchitis

•' Enteritis

" Laryngitis

" Meningitis

" Peritonitis

OL.A.J3S 3.

LOCAL.

-ORDER I,— Nervous.

Atrophy (Spinal) ;......

Apoplexy, Cerebral

Apoplexy

Congestion of Brain

Epilepsy

Inflammation of Brain

"• Cerebro-Spinal

Myelitis1

Hemiplegia

Chorea

Softening Of Brain

jjrr f f •*** F

^T3Bft(Wi?^!fcn4a<orj/. i C

An*gina^Pectoris|.!.,. <

Aneurism'..'.'. f...^..* <..

D@ |fW^}-|«v

Embolism (Cerebral) .* ,

Endocarditis

Fatty Degeneration of Heart-

Heart- Clot r,....Hypertrophy of Heart

Thrombosis, (Pulmonary)

Valvular Disease of Heart

ORDER 3,-~Respiratory.

Bronchitis

Hydrothorax

" (Typhoid)

ORDER 4. — J'igeative.

Ascites., „

Colic (Bilious)

Enteritis, Chronic

Gastro-Enteritis

Gastritis

Peritonitis

Fatty Degeneration of Liver..

Hepatitis

ORDER 5i-^~Urinai'y.

Cystitis

Diabetes Mellitus ;..„. ,

f '», ''" f * i J\ t\ 1, 1 *

,, P^ostatiiis.....,..",. i^m^i

ifrajmia'..^..^..!'., V(A,.^

^ Oto'^JSntfte.0.

^ , J *' * ^ ' M

Metro-Peritonitis (not Puer-

Ovarian Tumor u

. Ovaritis ,.

Uterine Tumor ,..

ORDER 7.— LocomotoryOsseous.

'

Lordosis (Cervical)

/ ^ORDER 8.— Locomotonf^lfnte^^mentary.. *jjr4

''/' * ^

Carbuncle,. ..Ig... , C.".»

Cellulitis .X ^rf....Xy " *"»

Eczema (Impetfgmodes) ^

, P ( >l **"'•" .

DEVELOPMENTAL.

ORDER 1.-^- Children.

Congenital Debility

Haemorrhage (Umbilical)

ORDER 2. — Women.

Chlorosis

"/ i " (Vomiting)

' Puerperal Convulsions

'1 ) ketritJs..^......;

'*,-. /Peritonitis

" "\ Septiceemia

Exhaustion i from TediousLabor SL .".»

v "

, ORDER 3.— Olc/f&ge. .

f Gangrene (Senile) 1

OEDER 4.— Nutrition.

Asthenia

Atrophy >.... .'

CL-A.SS 5.

;k VIOLENCE.i^T >

k OKDE^R 3 .— Violent Deaths.

Drow'ned ^Ac^dental)

filled by.Lightning.

'*• poisoned by

Shock from

Suffocation (Accidental).......

C }

ORDER 3.— Suicide.

Suicide by

Poisoning

Gunshot....

Drowning

Cause not ascertained

Total

Stillborn

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 known to me to be reputable and entitled to credit, and who, being duly sworn, declared in relation to aforesaid case

as follows:

OTE.—Affiants should state liow they gain a knowledge of the facts to which they testify.]

>?%> .. .<=^^^^

:i .:..f ^tfg>- <^5i>-Z^:

n/ sy ,c / /

.&3^

no interest in said case and

AD

DIT

ION

AL

E

V-I

DE

NC

E.

Pri

nted

and

for

sal

e by

J.

H. S

Otr

tti;

Was

hing

ton.

D.C

.

1 / 4 '' |J., f /EAJCE1 J

*f davit is, prepared from1 inemojr-knda i

t* ML * " ' ' "

0tdte of-.

Hi-;.- i -••^WAVi" V * > * ' '^t v

^^ . Pip-fUK' .' - f ", |t^y*hand,wfitmg^f ''thjs' afflafityihe marginal instructionsi-'1 ^l^beffaplip 'injpossgSaio'i, of aiffi'ant as to the oragin andief'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.--

(pompany and regiment of service, iMn the army; and rank il In tne navy.)' , t I', *

,, 4-VS,V.f5 ' ' ' ' " ; ' X>^ "V ' ', ii » ' ^ <Sf-^ ' 4 'S ' t"' (' ' '

Mp'>". , !'"' Per^lljy came;,befpre me,a,....-~:. £l :!^^ f6r the

»/«*'/'•"

whose;PostiO%ief^Jiaii»es^ is-

well known to; me to1 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 — X-- ------ years, and thatt — X-- ------

(Here embody all the fapts known to the affiant In accordance with the marginal instructions. No erasures or interlineations will be permitted" * x?" X t

unless the magistrate certiaes in ms jurat that they were^made before executing the paper/

of - obsphysical ooiwitiwhether as'lfamily physician oras a neighbor; andhow near he haslived >to him. Ifhe knew that thesoldier was a soundmam at enlistment,he should so state.adding, if true,thathad he" been un-soun<l,have known it.

If he treatedclaimant while inthe seivioe either'as hid regimentalsurgeon or while

"olainiant was homeon 'furlough, thatfact should bestated. Tbeolatta-ant's physicalcondition top suchtimes'shoula'.'beclearlOf 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.

(Affiant'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

,'

(Official Signature.)

••—V,

, ,,, ..,.,11, , ct•. '*•,-• ' 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

, NOTE.—This should be Sworn to toef6re a CLERK 'Sp COURT," NOTARY' PUBLIC oV'trUSTICE OF THE PEACE.If before a JUSTICE or NOTARY, then CLERK OF COUNTY COURT must add his certificate of character hereon, andnot on a separatetslip of-;paper. • '

. s, N * J t*« <ws$W#**< > *i»U»! • *

uwQ

U

w7 ';

fiM

£• S'

, B

Si

S

£&_..; %rtttjt8?<j;

.iJsSSarifeS t t* ';,

* > - i ,. D. ISS^personally appeared before me 'j ' ' , , / „ , ON THIS

fa . in and for the aforesaid BtiuiLliy duly authorized to' administer oaths,

-S-aged— rtdsaat-years, a resident <^^^^f^S^^^..,.!^r^....^.!r^^-^. i \

,',- i*"'Vl

in the County of'-*° -.-T: - and State of .-

\\hoso Post Office address is ,-•

well known to me to be reputable and entitled to credit, and who, being duly sworn, declared in relation to aforesaid case

as follows:

V^.^ _^NOTE.—Affiants should state liow they gain a knowledge of 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 1 I 1, /1 v . /7^ ^/ .

tp prosecution, , 5>_ , < j ;< i? \

..!'V fSfrlt?'!' , > , , / , , < " ' , ' i\J - ' > ' , ' / ' , - ; " . * * ! ' ' ' -T^ ' • H''

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Widow's/ Declaration;

i must be Executed before ^ouri' o;

; Pension 'or Increase of Pension. '

Record or some Officer thereof having' Custody, of the Seal.1

, 00:StateON THIS day of. ...C/.&f&CZ^t&ttl. ................. _ ........ A. D. one thousand eight hundred and ei

personally appeared before me -CW?-Afe?^x ...................................................... of

of Record within and for the- towand State aforesaid

_.Q ,aged ....^}....O , years, who, being duly sworn according to law, makes the following declaration in order to obtain the/

Pensjon provided by Acts of Congress granting pension to widows: That she is the widow of.. /"x^ ^/szsy^—/^

/- /^ ~~1? /^.., •tfaokfrl.^£.&?.££.-..under the name

^...^^^Jf^^...ff^f^^^^.^...^....^.^...^ , oi^the /.^y^^dayj^ -sfZ^Z- ^f? _ / „ (["_ „ ; -?

in ../.^__C2..-(Company and Regiment of service, if^n the 5-erressel and rank if in the navy.)

in the war of Z..4Z .<... ..rrZT~../:...£L..«S..eJ who(State nature of wounds and all circumstances attending them, or the

i and mamier in which it was Incurred, in either case showing soldier's death to have been the sequ- ' v . , ,^ ~

on the

who bore at the time of his death the rank of( I n the service aforesaid." or otherwise.)

...to Said.....rrb?^<^>^^2:c^that she was married under the

on the r^~..,..^r. day of

ere being no legal

barrier to such marriage; that neither she nor her husband had been previously married(If either have been previously married, so state.

and give date of death or divorce of former spouse.

that she has to present date remained his widow; that the following are the names and dates of birth of all his legitimatechildren yet surviving who were under sixteen years of age at father's death, viz:

of soldier by .C^ r ?^?;r»se2 fe rS«rrr..., born.^A£--^~-~/--~-- 18

if soldier by .tjf. (/.. , born ..£c ^^.of soldier by J\ b6rn ..18

of soldier by. . 1 , born J\8

of soldier by .A,. , born :l.---.... f.-=iv. L_.,...:. 18

of soldier by.. , J i..... , born __X— 18

. of soldier by.. ':..... , born \8

That she has not abandoned the support of any one of her children, but that they are still under her care or maintenance.

(For such children as are not under her care claimant should account.)

that she has not in any manner engaged in, or aided or abetted, the rebellion in the United States; that.....?.!!IZ^2r rj? '!" ~:

S /s? ^ ~">f^ ^*/s S* ^ ^/^ ^"*^ Sj's?

prior application has been filed £%^-<££^???Z^^^(If prior application has been filed, either by soldier or widow, so state, giving number assigned to it.)

: .,.y (..j£,g2?./

that she hereby appoints with full power of substitution and revocation,

her attorney to prosecute the above claim; that l|)(ff residence is

and her'Post Offldb'address is

,(Two witnesses who.ci

Also personally appeared..;J

residing &l..c&..<&&.^..-'&&f<(<d4f3<**ttrf. yy/(A£&?7TT. .persons whom I certify to be

/fan ~~f"—raspectable and entitled to credit, and who, being by me fiiiiy'swOfn, say that they" were preient and saw -./OOrf5£2T^&*£^t<l-.

IS&L). '.., the claimant sign her name (mafre-'hcr mark) to the foregoing

declaration; that they have every reason to believe fro-m the appe'arance of said claimant and their acquaintance with her that

she is the identical rjerson she represents herself to be ; and that-they have no-interest in .the prosecutioni :0f this claim,- • •>.-• •; •

(If Affiants 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 fally made known and explained to

the applicant and witnesses before swearing, including the words t _.^

..erased, and the words.,

prosecution of this claim..

...added; and that I havW n'6 interest, direct or indirect in the

0fl-H

O)-H

CO

WS

'04

GENERAL

p"

, 00:State of &J^L#^<xi*6*t. __. , Couritg of-In the matter of,.

ON THIS ....... « . . ..................... day of A. I). 188?"; personally appeared before me

in and for the aforesaid Coxinty duly authorized to administer oatns,

. 9aged S*-ff~ years, a resident of .•J?£^^^ifiilf^-2^^^^^i

'in the County of' .<^^rffe.--^s^te^ii?!'. ..... ~ ......... ........... and State of

well known to me to be reputable and entitled to oi'edit, and who, being duly sworn, declared in relation to aforesaid cuseas follows:

[NOTE.—Affiants should state lio»?r they gain & knowledge of then*trts to whioh'they testify.]y/?

^JQ.O interest in said case and - rl!?f!T*^Vrr3*it!r-..;..not concerned

in its prosecution.

(It Affiants sign by mark, two persons who can write siftn here.

Prin

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and

for s

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(3-56O.)

APPLICATION FOR ACCRUED PENSION.(WIDOWS.)

^Olinifl OjJ&J&£3^&-.rte-&r£<^&_____, Ss:

clay Qi ....^^f^.^^pf. , 188^personally appeared

-., "who, being duly sworn, declares that she is the lawful widow of

., deceased; that he died on the ^ferr. dayc~ i x- f~V v^7 ,s\ y~ /*>

of .^-^^fdAdd^^U/IA^^ is./J.; that he had been granted a pension by Certificate Fo. Zx^«-^l £_-£_.I i ~t/ ./ &, -^J ' •—?*- *./ ^which^rs herewith returned (or if not, state why not) ..^^...tfT^jZ^.t^^^fc^ —'

; that he had been paid the pension by the Pension

Agent at,/.t/^^.LA2/._/.L-^'^-----. up to the .___>#—— day of\_s

after which date he had not been employed or paid in the Army, Navy, or Marine service of the United

StateSiNkeajp^t- ^ /- •?- ; thatJb /t(, S/? ' // J?

she was, married to the said ^<^.-^>^^^.A^r^.<^i-ri^r^C~^?2t^-..on the ^v.<f^^^7^^-.— ^»^

in the State of/

.; that her name before said marriage was ..j^*?^f^S^f^:^.^

..; that shei»^^ had not) been previously married; that her husband

3 hacFnot) been previously married; that she hereby makes application for the pension which had

accrued on aforesaid certificate to the date of death; and that her residence^is No

street, -City of.-"—.- '—r',-V-': ., County of.

of.._^.^2^^^t^3e^^^ef. , and her Post-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

^ who, being duly sworn, say that they were present and saw

.sign heE-aaine-(inakc her marls)-to the foregoing declaration;

that they know her to be the lawful widaw of !ti_^<?L/L /.&^J^5^^ , who died

on the .-.../f-frp^. day of If^d^Ad^Q^^l.^ 1S<Q._; and that their means of knowledge

that said parties were husband and vrifg, and that the husband died on said date, are as follows:

.^^S3^^!l^£^^ ^^^,-. x y / S /^ ,t—^ ' /^ x s? , 7

. Sworn to and subscribed before me on this .^..-^—f. day of.

and I certify that the affiants are reputable persons; that they know the contents of their depositions, and

that their statements are entitled to full faith and credit. I further certify that I have no interest, direct

or indirect, in the above claim. "' ' "'•

(Signature:)

3:t—5M.)

(Ojfieial character:)

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State

.^AFFIDAVIT.^=fc

ON THIS

' < * " • # ' *..... :(3<*«*5SS5r. ...... <••*&

j <Zi—/ /"// / *r/ ....„...! day of... ^K^^k^^- L A. D. 188 y\y appeared 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, a resident of c

in the County of ,_^ rss£r 2>sfe*s?'. and State of

whose Post Office address isX

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 they gain 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.)

STATE or <s>^^^^< ...<fexf*fesfefe....,v. ......i.J , COUNTY OP .,r | I f r

Sworn 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.^ ..... '3x3<<€.- .......... personally known

to me and tha.t..j&>(.....4&ttZ. ........... credible person.^

(Offiflfal Character.)

I,.. ,.J?,.Z.-n., .: ,U , .,./...,/...<Srr. r .c,..r±r :±^- Clerk of the County Court in and for aforesaid County

and State, do certify that ^LJ.^^^^r^:!?.. ^.^^^d^^,, , Esq., who has signed his name to the

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. ^—

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.

Clerk of the

NOTE.—This should be sworn to before a CLERK OF COURT, NOTARY PUBLIC or'JUSTICE. OF THE PEACE.If before a JUSTICE or NOTARY, then CLERK OF COUNTY COURT must odd his certificate of character hereon, andnot on a separate slip of paper.

Kf-Wfl

oaaQ$W

zoIf*h>—IQ

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,

.saged .years, a resident of.....^fZtJrr-?r^^2-..<^rr-^rr^T^?T

ih the County of ^cfess^tz-^fes?. - and State Of

well known to me to be reputable, and .entitled to credit, and who, being duly sworn, declared in relation to aforesaid case

as follows: (2- %,,st ^ «Jr

[Nora—AfRants uld state ho^? the^ata a kjit6wleage of the facts to %Jiibh they testify.]

' £**<—£- e-^&t.

Post Office address is.i

.further declare that

ita .prosecution.

u

[If Affiants sign by mark, two persons;who can write sign here.] [Signatur

AD

DIT

ION

AL

E

VID

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.

FIL

ED

B

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Prin

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and

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sale

by

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Et B o B 05

1! !!

ACT OF MARCH 3, 1883.

INCREASE OF INVALID PENSION.

•Rank,

Company,

Regiment,

Attorney not recognized. JVo fee payable.

Rate, $24: per month, commencing March 3, 1883.

. . v / ^Disabled

Resulting in total disability, such iia to'rander

Submitted ..... , 1883, ly eJ...¥.S£.f./3^Jfc{j^.. ..... ... Examiner.

Approved.. .............. '. ____________ ...... . ............... r r ~ r r r ^ r f c r ...... _______________ , Reviewer.

A C T AUGUST 4,1686

IV

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8

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^4

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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

fr-

c

'CASE OF AN OBIG-INAL APPLICANT.

No. of Application, /£>f/

Applicant's serVice.

en Me teivice o,

tnva

'ate£, w-fio (4 an APPUCANT/• / J • / / / / / / ' /'#',nv-aua neiMion} fat ieaton of atteaed awafoMw 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,.

A P P L I C A T I O N F O R P E N S I O N .

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.

(MoTB.—This certificate should hot be detached i'roBl the accompanying papers, If additional information is deaired relative tothe case, tills paper should accompany tile application therefor.)

No.

NAME OF CLAIMANT,

NAME OF SOLDIER,

-.-Z^X^ -Z'—

(12172—50 M.) o 6—190