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, aged

who was a

Form of Declaration for obtaining a Widow's Navy Pension.
State (Territory, or District) of

County of
On this

day of , A. D. , personally appeared before me, of the

A B, a resident of in the county of and State (Territory, or District of

— years, who, being first duly sworn according to law, doth on her oath make the following declaration, in order to obtain the benefits of the provision made by the act of Congress approved July 14th, 1862, granting pensions : That she is the widow of

[here state decedent's service], who [here specify the time, place, and cause of death]. She further declares that

, ] she was married to the said

.

; that her husband, the aforesaid died on the day above mentioned, and that she has remained a widow ever since that period (or if she has remarried, and again become a widow, the fact must be stated], as will more fully appear by reference to the proof hereto annexed. The personal description of the said

her deceased husband, is as follows: [here state his age, height, complexion, occupation, &c.] She also declares that she has not in any manner been engaged in, or aided or abetted, the rebellion in the United States.

(Declarant's signature.)

on the

day of

in the year

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Also personally appeared and

residents of [county, city, or town], persons whom I certify to be respectable and entitled to credit, and who, being by me duly sworn, say that they were present and saw name (or make her mark] to the foregoing declaration ; and they further swear that they have every reason to believe, from the appearance of the applicant and their acquaintance

sign her with her, that she is the identical person she represents herself to be, and that they have no interest in the prosecution of this claim.

(Signature of witnesses.)

day of

Sworn to and subscribed before me, this

A. D. 186–; and I hereby certify that I have no interest, direct or indirect, in the prosecution of this claim.

(Signature of judge or other officer.) Applicant's post-office address.

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88.

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A. D.

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Form of Declaration for Minor Children, in order to obtain

Navy Pension.
State (Territory, or District) of

County of
On this
day of

personally ap peared before me

of the

A B, a resident of in the county of -, and State (Territory, or District) of

aged years, who, being first duly sworn according to law, doth on oath make the following declaration, as guardian of the minor child of > deceased, in order to obtain the benefits of the provision made by the act of Congress, approved July 14th, 1862, granting pensions to minor children, under sixteen years of ag of deceased officers and seamen ; that he is the guardian of [maming the minor child or children, his ward or wards], whose father was a

[here state decedent's service]; and that the said

- day of [here state the cause of death]; that the mother of the child— aforesaid died [or, again married, being now the wife of

-], on the
day of

in ; and that the date of birth of his said ward- as follows:

He further declares that the parents of his said ward

age,

died at

on the

in the year

the year

on the

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were married at

- day of - in the year by

(Guardian's signature.) Sworn to and subscribed, on the day and year first above written, before ; and I hereby certify that I have no interest, direct or indirect, in the prosecution of this claim.

(Signature of judge or other officer.)

D.

Form of Declaration for Mother's Application for Navy

Pension.

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A. D.

State (Territory, or District) of

County of On this day of

personally appeared before the of the A B, a resident of

in the county of and State (Territory, or District) of aged

years, who, being first duly sworn according to law, doth on her oath make the following declaration, in order to obtain the benefits of the provisions made by the act of Congress approved July 14th, 1862, granting pensions: that she is the widow of and mother of

who was a

[here state decedent's service, and personal description], who [here state the time, place, and cause of death].

She further declares that her said son, upon whom she was wholly or in part dependent for support, having left no widow or minor child under sixteen years of age surviving, declarant makes this application for a pension under the above-mentioned act, and refers to the evidence filed herewith, and that in the proper department, to establish her claim.

She also declares that she has not, in any way, been engaged in, or aided or abetted, the rebellion in the United States; that she is not in the receipt of a pension under the 2d section of the act above mentioned, or under any other act, nor has she again married since the death of her son, the said

(Declarant's signature.) Also personally appeared

and

residents of [county, city, or town), persons whom I certify to be respectable and entitled to credit, and who, being by me duly sworn, say that they were present and saw name (or make her mark] to the foregoing declaration ; and they further swear that they have every reason to believe, from the appearance of the applicant and their acquaintance with her, that she is the identical person she represents herself to be.

(Signatures of witnesses.)

sign her

day of

Sworn to and subscribed before me, this

A. D. 186–; and I hereby certify that I have no interest, direct or indirect, in the prosecution of this claim.

(Signature of judge or other officer.) Applicant's post-office address.

E.

88.

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A. D.

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Form of Declaration of Orphan Sisters for Navy Pension. State (Territory, or District) of

County of
On this
- day of

personally appeared before the of the

A B, a resident of in the county of and State (Territory, or District) of

years, who, being first duly sworn according to law, doth on oath make the following declaration, in order to obtain a pension under the act of July 14th, 1862: that he is the legally appointed guardian of [here give the names and ages of his ward or wards], who – the only surviving child-, under sixteen years of age, of and his wife, and sister- of

who

-, aged

was a [here state decedent's service and personal description], who [here state the time, place, and cause of his death]. That the brother of his said ward—, upon whom they were wholly or in part dependent for support, having left no widow, minor child or children, or inother, declarant, as guardian, and on behalf of his ward—, refers to the accompanying evidence, and such as may be found in the proper department, to establish her (or their) claim under the law above named.

He further declares that his said ward, is not in the receipt of any pension under said act.

(Guardian's signature.)

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Sworn to and subscribed before me, this

day of A. D. 186–; and I hereby certify that I have no in terest, direct or indirect, in the prosecution of this claim.

(Signature of judge or other officer.) Applicant's post-office address.

F.

The form of certificate of civil surgeons is here omitted, as the appointment of examining surgeons by the Pension Office obviates the necessity for examinations by any others.

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