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[[left margin]] June 17, 67 [[/left margin]]

I, [[strikethrough]] LA Gallaway [[/strikethrough]] Peter Moore, a resident of Brunswick County, North Carolina, am personally acquainted with Mary Moon (colled) widow, 3 small children and entirely destitute, who reside in Brunswick County, North Carolina, and state, to the best of my knowledge and belief, that she is entirely unable to maintain herself & family 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.

[[strikethrough]] LA Gallaway [[/strikethrough]] Peter Moore {Seal}

Sworn and subscribed to before me,    this 19 day of June, 1867

[[strikethrough]] Wm R Dothers JP [[/strikethrough]] W Lyman Capt US Inft Comdg fort

Note. - This Certificate must be signed and sworn to before some officer or agent of this Bureau.