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[[left margin]] June 19, 67 [[/left margin]]

I, [[strikethrough]] LA Gallaway [[/strikethrough]] JM McGowan, a resident of Brunswick County, North Carolina, am personally acquainted with Adaline Smith Widow, 2 children who entirely destitute, who reside Brunswick County, North Carolina, and state, to the best of my knowledge and belief, that they are entirely unable to maintain themselves and have no friends to assist them and are worthy of charity from the government, and   in danger of starvation if relief is not given.

[[strikethrough]] LA Gallaway [[/strikethrough]] JM McGowan {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.