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[[left margin]] June 19, 67 [[/left margin]]
I, [[strikethrough]] LA Gallaway [[/strikethrough]] Peter Moore, a resident of Brunswick County, North Carolina, am personally acquainted with Rachael Moorer (Collrd) 2 children in bad helth entirly destitute, who reside in Brunswick  County, North Carolina, and state, to the best of my knowledge and belief, that she is entirly 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 19th day of  June, 1867

[[strikethrough]] Wm R Dother JP [[/strikethrough]] W Lyman Capt 20th US Infy Comdg Fort

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