The Cnmmealth nf Mansarhusetta
This blank not to be used in Civil and Spanish War cases
Application for State Aid under Chapter 179, General Acts of 1917
To the Mayor and Aldermen or Selectmen of..
It is herehy Certified, that.
aged... .at enlistment,
having a residence, and actually residing in the City -Town-of..
Army Navy-of the United States, on the quota of Massachusetts, said.
is now serving [served] in the
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
, to serve..
years, where he remained until.
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 is now in said service, where he
remained until honorably discharged..
The official certificate of service must be filed herewith.
3
aged.
-years, residing in the City-Town-
of
do upon my oath declare and say that the above statement is true, according to my
that I am the wife-widow-mother-father-brother
best knowledge and belief-
sister-of the above-named.
...to whom I was married on the......
19
therefore respectfully make application for
day of....
.
f his death [absence] in said service I am deprived of my support.
and by reason
State Aid, as provided by law, having been dependent upon my said husband - son..
I further apply for my children; namely.
born on the..
.day of..
19.
day of.
born on the..
19
born on the
day of.
19
born on the..-
day of....
.19..
born on the..--....day of.....
19
now living with and dependent upon me. And I further declare and say that I am in necessitous cireumstances, 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 Cnmmnnumealth nf Massarhuaetts
..191. Then personally appeared the above-
and made oath that the foregoing statement, by....
named..
subscribed, is true, according to..
best knowledge and belief.
Before me,
Justice of the Peace.
Carefully read the notes on the back of this blank before signing.
(OVER)
wife-widow-mother-father-brother
