The Cnmmanumealth nf Massachuaetta
Application for State Aid under Chapter 314, General Acts of 1916
To the Mayor and Aldermen or Selectmen of.
3t is herehy Certified,
aged.. at enlistment,
that
having a residence, and actually residing in the City-Town-of
--, is now serving [served] in the
Army Navyof the United States, on the quota of Massachusetts, on the Merican border.
Said..
enlisted at.
.and was mustered into
.
Company.
Regiment, Mass. Vol..
-in the service of the United States on the
day of
in the year 191
-years, where he remained until
, to serve..
the..
.day of.
in the year 191.
, when he was honorably discharged for
the Naval service on board the U. S. Vessel called the.
and
now in said service, where he
remained until honorably discharged.
D
The official certiflcate of service must be filed herewith.
-years, residing in the City -Town-
aged. -
of
,do upon my oath declare and say that the above statement is true, according to my
best knowledge and belief-
that I am the wife widow-mother -father brother-sister-of the above-named..
-
.day of.
. .to whom I was married on the.
.19.-;
and by reason of his death [absence] in said service I am deprived of my support. I therefore respectfully make application for
State Aid, as provided by law, having been dependent upon my said husband- son..
further apply for my children; namely
day of...
born on the...
19
.born on the.
..day of.
19
born on the...
day of.
19.
born on the...
19
.day of....
born on the..
day of...
....19..
now living with and dependent upon me. And I further declare and say that I am in necessitous circumstances, that I am not
receiving aid under Chap. 587, Acts of 1914, nor from any city or town in this State, but that I am [not] in receipt of a pension
from the United States of $.
per month, dating from...
Dated..
19
(Applicant to sign here,)
The Cnmmnnmealth nf Massarhusetta
191.. Then personally appeared the above-
and made oath that the foregoing statement, by...
named...
.best knowledge and belief.
subscribed, is true, according to..
Before me,
Justice of the Peace.
aCarefully read the notes on thee back of this blank before signing.
( OVER )
