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_ of _ }
County of _ } SS.
On this _ day of _ A.D. 18 , personally appeared before the subscriber, _ in and for the County aforesaid, duly authorized to administer oaths, _ a resident of said County, to me well known as a credible witness, and who, being by me first duly sworn, doth on his oath state that he is acquainted with Mrs. _ the above applicant for Bounty; that he has known her for _ years past; that he has examined her family record; that he believe the same to be genuine; that it is contained in a book purporting to the "_," and printed in the year _; and that the said record, as far as related to the marriage of the said applicant and the soldier above named, and of his death, is as follows, which is an exact copy of the same: _ and that the said deponent is not interested in the claim.
Subscribed and sworn to the say and year first above written, before me, and I certify that I am in no manner interested in said claim.

_ of _ County of _ SS,
I, _ Clerk of the County Court in and for the County and _ above named do hereby certify that _ Esq., before whom the foregoing affidavits were made, and who has thereunto signed his name, was at the time of so poing a _ in and for the County and _ above named, duly commissioner and sworn; that all his official acts as such are entitled to full faith and credit, and that his signature thereto is genuine.
In TESTIMONY WHEREOF, I have hereunto signed my name, and affixed my official seal, this _ day of _ 18
_

WIDOW'S CLAIM
FOR
Retained
BOUNTY [[strikethrough]]& BACK PAY.[[/strikethrough]]

[[strikethrough]]This blank is published for the sole and exclusive use of CHIPMAN, HOSMER & CO. ATTORNEYS, 446 14th Street, Washington, D.C.[[/strikethrough]]

1. Claimant's name. 2 Soldier's name. 3. Soldier's rank. 4. Letter of Company. 
5. Proof of Marriage. - If there is a County, Town, or church record of the marriage, a duly certified copy of such record must be sent. If there is no public, but a private or family record containing the marriage, a copy of such private record should be annexed. Parol evidence of the marriage is not admissible until the absence of record evidence is accounted for. If the testimony of persons who were present at the marriage can be produced, it should be sent; and if such testimony cannot be had, the will widow will so state. Testimony to cohabitation and general repute as man and wife will not alone be sufficient proof of the marriage, unless the claimant is unable to present either public or private record evidence, or the testimony of persons who were present, and so states in her declaration.
6. Witnesses will here state in what manner they derive their knowledge of the soldier's identity and of his death; and if they or either of them were present at the marriage, it should be here stated.
7. Witnesses' Signatures. 8. Magistrate's Signature. 9. Died or was killed.

Transcription Notes:
11.28.2023 - Transcribed per guidelines and marking for review