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I, Edmin Levy, a resident of Brunswick County, North Carolina, am personally acquainted with Luke Sellers & wife destitute, who reside in Brunswick County, North Carolina, and state, to the best of my knowledge and belief, that they are unable to maintain themselves and    no friends to assist them and that they worthy of charity from the government, and   in danger of starvation if relief is not given.

E Legg {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.