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I, L. A. Galloway, a resident of Brunswick County, North Carolina, am personally acquainted with Easter Gause, (Collerd who is blind destitute,  who reside Brunswick County, North Carolina, and state, to the best of my knowledge and belief, that She is Entirely unable to maintain herself and has no friends to assist her and is worthy of charity from the government, and is in danger of starvation if relief is not given.

L. A. Galloway {SEAL}
Sworn and subscribed to before me,  this  day of  , 186
 
NOTE. - This Certificate must be signed and sworn to before some officer or agent of this Bureau.