G Chn4
American Agencies for War Relief
Civilian Relief
Investigation and Record Blanks
The Commoumealth of Massachusetts
Application
State Aid under Chanter 314, General Acts of 1916
To the Mayor and Adermen or Seleetmen of.
brrebg Certifird,
31
..and...
a esl t,
o Moni vg eed in the
nlitod at..
Ja de arvi of-
Compasy
it, Man Toa
e de yee 190..to wre
n the year 191
u, whe he msnd wat
when be was berbly darbarged for
...
l the. and is scw is id i, whe be
-The official certitonte of service must be tled herewith.
, ading in the Cty-Tes-
d
eling to am
newlden and belid-tat I m the wiw
-l
dpdt apes ay t bohand-
eoTnd toy la, ang be
te. y of....
..19...
o living wh d depodes pon me And I beser detur nd y that
se
eoeiving aid der Chap 47, Arts of 14,
be United States of $..
y ity er so in the Rale, lt dat 1
oh mevid of
mesth, daces fre
The Commmumealth of Massachusetts
Thes peroaly appened the sbove
13
Only the wing clae are elighle to apply on thia Mank, vis.a
bet kogale
setally depedest
edebel, i tron, soling tn
r be aided ir
e se ease can mem than 830 be paid so ee fr all the dependent rstiees of sey cee elder or alor in a
rone poesh
Jutior of de Pn
y
Bes n der ate Ail sedor this be cely fm the
y or ass is whih the
Carefullr read the notes on
he
of this blank bedore signing
r ioyER
