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NARA 495

(No. 25.)

Cert. No. __
CLAIMANT. __
Late __
Co.__
Regt. __

U.S.C.T.

Amount due $ __
BY WHOM WITHDRAWN. __

OFFICE MARK.

__ A.G.O.| F.B.| 187 .

Transcription Notes:
---------- Reopened for Editing 2024-05-28 09:43:28 Added NARA page Fixed to reflect fill in form for readability.