widows pension app of martha cassidy rhodes

8/14/2019 Widows Pension App of Martha Cassidy Rhodes

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(/ .;DJ!CLHRHTION FOR jt!IDOlV'S PENS] ORr J"; AC T OF J UNE 2 7 TH , 1890 .

That she is withoutmeans of support other than her daily labor. Th th names and dates of birth of all the children now living under sixteen years of age of

e soldier (or sailor) are :IS follows:

~ u : 2 . L k : ......,'Y=:' born ........ 2 ; ; : l . u - L ~ .....1/............................. .born ....... , 18......

............... . . .... .... born ....... .......... ... .................. ... ........... 18

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she makes this declaration for the purpose of being placed on the pension roll of the United States unde, the provisions of the Act of June 27,

She hereby appoints, with power of substitution, MIL 0 B. S T EVE N S & CO., of ..Cl!!ftAI.'6itHt(, .. @ i ! t : ; . ~ ; . successors or l A ~ a l representatives, he r true and lawful attorneyS to prosecute he r claim and recei ve a fee of Te n Dollars. Thn t her post office. .

....................... y of . _ .... .......... . d T ~ _ a . < 7 C C ~ State of. .... p . & ~ ~ ... " ..-) ..... ... : L i ~ . /..~ C ~ ~ , ~ _ { .. v / t / ) 1 1 . ~ / .. 11: j/lrt'i4:!'Sit(n .. t u r ~ of C\';).';m:\ntJJ.l... ..... ...:;lt..~ . ~ 4 l 1 ~ : ~ .

Tw o witness#3 who can "rite:, s.ign hete. SEE OTHER SIDE.


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.- '.. t-_&T. f\uGulir'Ni,s @HURCH:.

REV. J. L. BRASSART.PERRY COUNTY.

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REV. J. L. BRASSART.PERRY COUNTY.

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, READ TH E INSTRUCTIONS ON BACK O F THIS BLANK BEFORE USING IT

3-044

APPLICATION FOR REIMBURSEMENT This form not to be used i f the deceased pensioner left a widow or minor children under sixteen years of age

STATE O F - - - - - - - - - - - - ~ - - - - - - - - - - - - - - - } 8 8 : COUNTY OF______________ ~ - - - - - - - - - - ______ _______________ _

On this______ ?___________ _ _ ______________ , A. D. 1930. before me, the undersigned, personall appeared~ ~ u : a . . ~ ~ I ! : : a : ~ . . c : . . . . ~ _ c : - - - . _ __, aged ____________ years, a resident of ______ ~ - ' _____________ ,

f . l . : : : . . . . ~ ~ r : ~ ' l : - .. -----------, State of - - - - - - - . . c . / ~ , who makes the followingapplication for, and claim i eby made for, r e i m ~ B e ~ t fro?e accrued pension for expenses paid (or obligation incurred) in thelas,ckness and burial oL _ ~ : _______ , who was a pensioner of the United S t a t ~ c e r t ~ t e No. _ ~ Z ~ _ . l . 3 . __ ,and who DIED ____ ~ - . L - - ~ - , 1 9 - ~ 4 & t - - - ; - - - ~ - - ~ - r - - - . ? ' f ~ - - ! - - -an d was buned at - ~ .. -- - - - - - - - - ~ 7 - - - c . ! J ~ 1

That th e answers to estions propounded below are- full, c ~ e t e , an d truthful to th e best of my knowledge, information, andbelief, and that no evidence necessary to a p r o p e ~ a d i u s t m e n ~ f _ all c l a i ~ s . , a ins t th e a c c r u e ~ ~ r withheld.

1. Wbat was th e full name of th e deceased pensIOner? - - - - ~ - - - - d . - - - - _ __ ______________________2. In what capacity was decedent pensJoned? (As soldier or sailor, or as a widow, minor child, dependent relative, etc.)

- - - - - - - - - - ~ - . - a - - - - ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -3. I f decedent was pensioned as a soldier or sailor

(a) Was he ever married? (Answer yes or no.) ___"________________ .::::::". ____________________________________________________._________________________(b) How many times, and to whom? ____uu ______u_u_uun __ _ n __ n""_______ nn_n _________ nn __ uu __ _un __ __ un _ _ _ _ _'u_n _____ u ____ n __ u_uu

(c) I f married, did his wife survive him? (Answer yes or no.) ________ u m _ ? : ' ~ u _ u m_u m _ _ _ _ _ _ m_unun n __ _ n ___ __ m ____ __ m _________ nn ______d) I f so, is she still living? (Answer yes or nO.) ______________________ "== '____________________________________________________________________

(e) I f no t living, give full names an d dates of death of all wives __________-====_________________ _____________________________________________(J) Was he ever divorced? (Answer yes or no.) _____________________________=:::.________ ._____________________________________________________________(Il) I f so, is the divorced wife still living? (Answer yes or no.) _______ ::-::::-::::_________ (I f living, a copy of th e decree of divorce must

be filed.)(h) I f no t living, g-ive her full name and the date of her death_______ m _____ m_u-== __mmm __ _nu __m_m __m_mmn _________________________ _

4. Did pensioner leave a child under 1G years of age? (Answer yet: or no.) _______ ~ - - - - - - - - - - - - - - - - - - - - - .. ------------------_____ ._______ . __ _5. Is any such child s/'illlh-ing; (Answer yes or llO.) ________ __ _______ . ::m _________ u _____ u ____ m _______mm u __________ _mmn ________ m _______ n __ _6. 'Were any sick or death benefits paid on pensioner's account? I f so, give name of society aud amount paid_________________________________ _

-------- ------- -- -- --_. -- -- ------- ----- --- ----------- -- --------------- -- --------------------- --- --_.---------- ---_.-------------------- ------ -------------7. Was there insurance (life, accident, or health) in force on life of pensioner at time of death? (Answer yes or no.) _______~ - - - - - - - - - -8_ I f so, give the naIile of each company in which a policy was c.arried and th e amount in which each policy was written_____________________

9. 'Vho was th e beneficiary named in each policy?_. ___________________________________ ...________________________________________________. _______________________

10. 'Vhat was the rclaiion of eaen beneficiary to the pensioner?______________________________ .____ . _________ . _____________________________________________---_II . Were the premiums paid by the deceased pensioner?_m _ m __________ . . __ ......-::"______________: : . _______ m ___ m ______ . ______________________________m ____ _


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-----_.--- --------- ----- - - ~ - -----.----.--._., --'" -._-------------------_ .. --- -----. ----- ------_ ....-----..---- -------.- --..-_..-----------..__ ._....-_.-----tho doo..... p e n t i o n ~ 1M.. mon,y, , ~ I . . t a " ] ! J : : ~ p e 2 . - - ~ 2 = - - - - - - ' - - ~ ; ; ; ; ; ; ; : '

I f ~ " ' : : : : : 2 ~ U ' of y_- - ~ - : : : - : : - - - . ? : : i a . ~ ~ : : : : = ~ - : : : : : : ~ : ~ : : : - - ; - " k - - : - - - L .n,noh P'OPorl ___What was e assessed value (last assessment) of the real estate? ___~ - _ ~ ~ I I ! : . 1 f ' : ~ _ ~ ~ __.:-.:l2 ,HO_W__= _ t h ' = i ~ n - , ~ ~ , _ p ~ O : : _ ~ i ' ~ ' ~ _ ~ , , : : : : : : = : : _ : 2 " ' : : _____~ ~ : ~ : : : ' : : : : : : - : : : : : : : : : : : : : : : : : _ : : : : : : : : : = : : : :

leave an unindorsed pension check? (Answer -es or no.) ______ ----- --.-------...- - ~ - - . --- .....-.- ......--.-.-What was your relation to th e deceased pensioner?.__:_ _ ____.. _ ____ __.___.. . __. _______. ___.._._. _____________ ._.._.... __ ..__..____.__Are you married? (Answer yes or no.)__ ...._ ._. ______ ~ - - - _____________ ___________________________. . __ _________ ______._. ________. ___________ _" 'ba t was the cause of pensioner's death?_____________ __ _ _ _____ . ________ .. _. ______________________.____________ .________ .When did the pensioner's last sickness begin?_.______ ._._... 2 . . - - ~ ___ ~ f - - e . . - - ~m - .- -. . .From what date did th e pensioner become so il l as to require the regular and daily attendance of anot eT person constantly until

death7_____.________ .________ __ ____ ._. ~ ~ . - - - - - ~ - - - - __ .2._.a_/_.__ L ' ? ~ _ t 2 - - - . - - - : : - - . - ..--.--.-.... G i ~ : . ~ ~ _ ~ . ~ : : . ~ _ ~ n ~ ~ ~ . ; ; . ~ ~ - ~ s s of e a c ~ P _ h Y S i c ~ . n ~ ~ ~ _ ; : ~ ~ ~ U 2 - ~ U r i n g - l a ~ t s ~ ~ ~ ~ ; _ ~ ~ ~ ~ ~ ~ ~

---------------------------- - - - - ~ , , - - - - - - - - : - - - - - - - - - . ---------- - - - - ~ - - - - - - - - - - - - ------------ ._-----------------State the nam.es of th e persons by whom th e pensioner was nursed during the last sickness.._._. __..._._. . . ._._. _______. _._. __________ ____ ..

: ~ - - : - - - : - - - ~ 3 ! ; : : : ~ - - : ~ - : ~ z . Where did th e pensioner live during last s i c k n e s s L ~ . ~ _ m _ _ . m_. __m ___~ _ . ~ ~ . _ .. "Has there been paid, or will application be made for payment to you or any 0 her pel1!on, any part of the e x p e n s e s - ~ f & pensioner's

last sickness and burial by any State, county, or municipal corporation? (Answer yes or no.) __ . .. _-::::. ___ L _ ~ t 2 . _ : __Th e following is a complete statement of aU th e expenses of the last sickness and burial of said ~ e a s e d pensioner:(Eacb charge entered below should be supported by an ite!llized bill of the person who render"" the sem"" or ft:t.rnlshed any supplies for which reimbursement Is demandedshould show, over his signature, by whom paid, or who is held responsible lor pa;-:roent, a.nd oontain the name of the pensioher for whom the expense was incurred or service

I f DO cJw:lle was made for any item, that lact should be indicated.

ST ATE WHETHERNAMES :t\ATURE OF EXPENSES AMOU:t\TPAID OR UNP.'I.lD...---.-..----..~ - ; ~ ~ ~ ~ : ~ ~ - ...---.-.._=-. - t P ~ . _..._.2_.5._'__..!!.P: : : : : : : ; : - - ~ - = ~ - - : : : : : : - - - - : - - : : : : : : ~ ~ ; : : : k : 2 : j j : : ..-.-- . _____ . ._......... Underta.ker._._.__ __._. ( f ' ~ ...._._I_..2.l.Q. __ ...__. Livery________.____._._ . . __ ____._ . .___ ._1.._......__....___ , ._

. _ _______________________ ________________ ._________________ __ . __ . ___. __ . __ ______ . ___________.. _ ____ __ ___ _____ Cemetery____________________________ .. . I .. ________I ..Other expellSM a.nd their nature: j

That of the above-mentioned expenses this claimant has paid"; o? guaranteed th e payment of, th e following Items : ___.______. ________
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who, being dulyth e following questions are true:1. Did pensioner (if a soldier or sailor) lea.ve a widow or a minoe' child under age of sixteen years s u r v i v i l l g ' ~

= ......--..... ~ ----- ---------- ------ ----- --- -- ---- --- ----. ",'. --- --- ------------- ------------ ------,/2. Wh" did th ' p",ion" di,L............. .. . ......L... .. ......L..? .... .....:...3. D i ~ = " 1 ~ n ~ T ' Z L . : . : d 2 d . : ~ ; . : ~ . . .....::.....

- - - - - - - ~ - 3 - b - t 2 - - L - - - - - - - - - - - - - - - - - - -4. Our means of knowledge of th e above statements made by us ure: We kr:ew t ~ e \!i1r:eased pensioner for __3(1. __ycars and____/f'-O __

: . : ; ~ ~ : j ~ : ~ ~ ~ . : : : : : ~ : : ; ~ i ~ ~ ~ ~ ~ i ; " : ~ ~ ~ ____________________________________ D.ubscribed an d sworn to bef te me, th iL ____-6.._____________da y oC___________ _ _ _ A. 19_..14' '

and I certify that th e contents of th e foregoing application were fully made known an d ained to the claimant and witnesses beforeswearing, that I have no interest, direct or indirect, in the prosecution of t lis claim, an I further certify that the repubtion for eredibility of th e witnesses whose signatures appear above is___ ___. ~ ~ ~ 2 ' : ' : ~ ' C .

Give name of any other physician who attended the pensioner in last sickness____ ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

; : L ? g : i z . ~ . ' n : ..'".t':.'::;;;""t. -a2- ------- --------- ____Y7k___ ~ - - - - - - -Attending Physician. __________________________________________________. 19_____ A.ttending Physician.-1672


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:MEDICAL DESCRIPTI V . L l ~ Ward ...... { B e d ~ Gener"ft,'Pi;al a ~ ~ _ ~ ___N a m @ j i ~ ~ { / ( J f ~ ..Age . ......... ,Rank . /MM.k , 0Ij:4'1. Regiment ....... . ( . ~ _ . Lo r 11 . d: - . J If A d m i . s s i o n ~ . M j l . .../L4d!.. ............................._................Dlse se or Injury, 1.1:.. ;;!...... Return to duty, cured, .It{..CiA..(2,:I.Y..tfh. ...Lt[/;!: ..

Result,....................................................................................... ................ Ip, l h "-INomoo' .............1omOM.] DATE OF j D : : c ~ , ! g : ; ; ~ ; ~ ~ ; , , : e , : : . : : : : M J . /? - / I/ lTransfer to anoiller Hospital, ". ..,.. .H.. I 1-.......................Lk!.......z:r....... ~ . _ ~ ~ .................

NOTE.-Whcn6 ~ e n : is : t 'r : :Z : 6 G:k:Piial. the entries on t h i , ~ : ~ C : t i ~ ~ ~ i s t ~ 1 1 1 ~ e ~ o ~ ~ e ~ ~ ~ ~ . . .Al I important C b a n ~ ~ ~ " : ~ ' ~ i ~ cOllelition will be noted on it , (in ink,) from tiIne to tilLe, by the in cha.rge of ,:'e Ward. When the patient has been wounded, the d;lte and chamClerof the wound will be stated, the nature of the operation, (i f abo>'e all, the result. In case of transfer, this Ii,t will be sent. through the O f f i ~ e r incharge 0 the transportation, or failing one, by mail, to the Surgeon in cbarge of tbe HOi;pi!31 receivil:!j' Ihe patient. \Vhen this lI1euical History shall havebeen completed, by tbe cure, d i ~ c h a r g ! ; l , furlough, or death of the patient, it will, with the treatment and result, carefully noted, be transmitted directly to th6Surgeon General.T R E A n I E ~ T . I DIET. RE)'IARKS AS TO C O ~ ' 1 ) I T I O N OF PATIENT, &c.ATE. I

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O A S U A L T Y S H E E T .

J { a m e , ~ ~ _ ......Rewk. ~ - - - _ . Company I ,Regiment, ? / . ~ Arm .. ' ~ - - " ~ " " " " . State, ............. ~ ..._............____ ...

Place o f casualty, ~ ~ .. u ..._u._ . . . . h __ __ hh : ;;;:;

Nature of casualty, ' ~ ~ ~ . . . & : ~ . u . _ . ; > _ .._......... ... h.h U m

fROM WHAT SOURCE THIS INFORMATION WAS OBTAINED

. RCp01tOj' ICillerl. -ff'uunrirrl, (1 nd .llfissilJ,Q of 'lie 21'/j1 Br ignde , / . Division. .... Corps, dated

M ... / ~ 7 - L 2 ~ / ~ . . ) ... .... # ... ~ ~ ....

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widows pension app of martha cassidy rhodes

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