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[[stamp]] THE NATIONAL ARCHIVES OF THE UNITED STATES [[/stamp]]

Received of Capt. W W Deane A.A.G. May 1866 the following blank forms viz 

Ten (10) "Declaration for Invalid Pension"
Three (3) "Application for Prize Money" and
Three (3) "Power of Attorney" and 
Ten (10) "Declaration for Minor Children's Pension"

H.C. Strong
1s Lt Actg ASA Com'r