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I, John C McHenry, a resident of Wilmington N H County, N. C., am personally acquainted with Jack Smith, destitute freedman, who reside Old Tower Brunswick County, N.C., and state, to the best of my knowledge and belief, that he is blind & Consumptive and unable to maintain himself & family and has no friends to assist ...., and is worthy of charity from the government. 
These are three persons in the family
J C McHenry {SEAL}

Sworn and transcribed before me, John J Conoly JP, this 22nd day of June, 1866

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