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I, Rufus Gallonay , a resident of Brunswick County, N.C., am personally acquainted with Mrs Mary Potter that she is, destitute and that she, [[strikethrough]]who[[/strikethrough]] resides in Brunswick County, N.C., and state, to the best of my knowledge and belief  , that she is unable to maintain  herself, and    that she has no friends to assist her, and that she  worthy of charity from the government.

  Rufus Gallonay {Seal}

Sworn and subscribed to before me,  , this   day of  , 1866.

 

Note. - This Certificate must be signed and sworn to before some Magistrate, Justice of the Peace, or officer of the army.