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[[left margin]] June 22, 66 [[/left margin]]

I, Miss CV Henry, a resident of 2nd & Ann St. Wilmington [[strikethrough]] County [[strikethrough]], N.C., am personally acquainted with Mrs Hester Ann Lockey & family, destitute Refugees, who reside on 6th St near Orange Wilmington [[strikethrough]] County [[strikethrough]], N.C., and state, to the best of my knowledge and belief, that she and her children are unable to maintain themselves and have no friends to assist them and that they are worthy of charity from the government.
CV Henry {SEAL}
Sworn and subscribed to before me, 2nd Lieut EH McQuigg Asst Supt Sub Dist of Wilmington this 22 day of June, 1866
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Note.-This certificate must be signed and sworn to before some officer or agent of this Bureau.