Ch174
American Agencies for War Relief
Civilian Relief
Investigation and Record Blanks
The Commonmealth nf lassachusetts
This Mank not to be sand in Cirt nd Seaeish Far ce
Application for State Aid under Chapter 179, General Acts of 1917
To the Mayor and
r Seleetmen of.
havie smbner nd sy
A -Sary- e d th d
e n the Cay-Tows-o
nd w teed inie
..eginest, Ma Vel
Ja the sevie f the Uaitod tat n thas
Compy
das
shen be wae benndby dieharmd for
widw wheo be
wainad et besbly abuod
The offeial certiteate ot service uat be iled berewith
3
in the Cty-To-
de spes
cath dle and y at the sbee tademet la trae, acoondinr to an
o
.
..
Irethrl
T the sloveeaa
...19....
ia d tly ake wplts r
born en the
ay
I farther apply for s
r hldron; naly..
19..
am in seoon eleratanos, that I am not
dhel ta ot of a pele
now ving with and dependent upon me Aad I fertber decle sad my thale
nta of
Thdel
The Commonmealth of Massachusetts
Ochy the feeing da
elighle to apply on the blank, vi
a
The ponaly appeared the abeve-
101
The wie sod ehide (wile her bbnd is in he srvioe, be widow, a the taer, or, be
whea aetally
bet ino nd eade oh that tbe gng , by
drgendnt ay be sided in eesito eirtano
e ,
la so ce can oe than $40 be pald to ar foe all the dependeat nlatives af any se lder or saor la say e
Juniar of le Pe.
Pe
sdally ide,
drew Sale Aid d thie lw nly tra the y or tow is whie
e baok of this blank bofore signing.
aer Caretully ad the nesee om
roves
