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I, Rufus Galloway, a resident of Brunswick County, N.C., am personally acquainted with Alina Davis and that she is destitute and that she, [[strikethrough]]who[[/strikethrough]] resides in Brunsick 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 (except and old Husband), and that she is worthy of charity from the government.

Rufus Galloway  {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.