NAVAL-REGULATIONS AND FORMS. the President respecting the army and navy, and calling out militia and volunteers, were legalized by act of August 6, 1861. U. S. Statutes at Large, vol. xii, 326). That he entered the United States naval service at —, in the State of on the day of -) A.D. 18-, and while attached to [Here give the name and class of vessel] and holding the rank of [if not an officer, say, after name of vessel, as a seaman (or ordinary seaman, or boy, or otherwise, as the case may be), he was disabled [Here state when, where and how the disability was incurred, with a minute description of the injury or sickness, and how the applicant is affected by it]. That the same was incurred by him in the performance of his duty; and having thereby been disqualified for the naval service, and disabled from obtaining his subsistence by manual labor, he refers to the certificate of Surgeon herewith presented [If no certificate was obtained, state the fact; if obtained and lost or destroyed, state particulars of loss or destruction], and claims the benefit of the laws granting navy pensions and that his pension may be made payable at the navy pension agency in this (Claimant's Signature.) day of, A.D., 18—. -, and believe him to Sworn and subscribed to, before And I certify that I am acquainted with the said be the identical person who served as aforesaid, and that I am not interested in his claim for a pension. (Signature of Officer.) This declaration must be made before a Court of Record or before a Judge or Clerk of such Court. Should it be made before a Court, the certificate to the affidavit just given will be omitted, and a certificate of the Clerk according to the form No. 5, following the next form of declaration should be substituted. NAVAL-REGULATIONS AND FORMS. (2) Affidavit of Witnesses. STATE OF 88. day of On this A.D., 18-, before me, the subscriber, a in and for said county, duly authorized to administer oaths, personally came, aged years, and, aged years, whom I know to be residents of the county and State aforesaid, and persons whom I certify to be respectable and entitled to credit, and who, being duly sworn, say that they were present and saw — execute the foregoing affidavit by signing the foregoing declaration, and making oath thereto in due form of law, and they further swear that they are acquainted with the said now present, and have every reason to believe from the appearance of the applicant, that he is the identical person he represents himself to be; and further, that they, deponents, do reside in the county aforesaid, and have no interest in the claim of said Witness: (Signature of Witnesses.) day of Sworn to and subscribed before me, this A. D. 18-; and I certify that I am acquainted with the said - and -, and know them to be credible aud disinterested witnesses; and I further certify that I am not interested as agent or otherwise in the prosecution of the foregoing claim. (Signatnre of Officer.) For FORMS and REGULATIONS relating to POWERS OF ATTORNEY in pension cases, see Chapter XVI. clerk of the (3) I, court in and for the county and State 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 doing a -- in and for the county and State above named, 'duly commissioned 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-. [L. S.] (Clerk's Signature.) court [or before me court], a court of record within and for said a resident of in the county of years, who being first sworn, according to who was a— in the naval day of county, personally appeared -, and State of, aged law, declares that he is the identical service of the United States; that he enlisted at in the State of , on the A.D., 18-. [Describe the service in which the claimant was engaged; if on board ship, give the name and class of the vessel, the rank and capacity in which he served, the name of the commanding officer, the engagement or other line of duty or occupation in which the disability was incurred; a full description of the time, place and manner of, in which the wound was received or disease was contracted; and its location, nature and physical effect]. He further says that he was honorably discharged, as will appear by his certificate of discharge herewith presented [if no discharge was received, state that fact; if lost or destroyed, detail the circumstances], on account of said disability, upon the surgeon's certificate for a pension [if the discharge was upon a certificate of ordinary disability, and the disability continued or increased, these facts should be stated], and recommending a discharge, as may be found reported by the commanding officer approving the same, on file in the Navy Department at Washington; for the existing degree and continuance of which disability he requests a medical survey may be ordered. He makes this declaration for the purpose of being placed on the naval invalid pension roll of the United States, and obtaining the pension to which he may be entitled under the act of [date and title of act], granting pensions to persons disabled in the naval service of the United States. (Claimant's Signature.) I certify that the foregoing declaration was sworn to and subscribed before me, this day of – A. D., 18—; and I further certify that I am acquainted with the said, and know [or believe] him to be the identical person who served as stated in the foregoing declaration, and that I have no interest in his claim for a pension. [L. S.] Witness my signature, and the seal of the county, court of (Clerk of said Court). Should the declaration be made before a Judge, the Clerk's certificate of his official character (under seal) must be attached. NAVAL-REGULATIONS AND FORMS. Should the declaration be made before a Court of Record, the Clerk's certificate may be as follows: STATE OF County of I, 88. - clerk of the (5) court within and for said county, hereby cer tify that the foregoing declaration was made under oath, and subscribed before said court, on the by day of A. D. 18-. Here must follow the affidavit of two witnesses, according to the form No. 2, given at the close of the first form of declaration for obtaining a naval invalid pension, p. 95. Should the affidavit of the witnesses be made before a Justice of the Peace, the Clerk's certificate to the official character of such justice (under seal of the Court), must also be appended. For REGULATIONS and FORMS relating to POWERS OF ATTORNEY in pension cases, see Chapter XVI. (6) Surgeon's Certificate of Disability. It is hereby certified that commanded by - Я--- in the United States ship of war is rendered incapable of performing the duty of a by reason of wounds [or other injuries, or sickness,] received [or contracted] while he was actually in the service aforesaid, and in the line of his duty, viz: in the year By satisfactory evidence, and accurate examination, it appears that on the day of being engaged [Here state, particularly, the duty in which the applicant was engaged; the harbor, navy-yard, river, bay or ocean, where the ship was, and the time when the injury was received; and give a particular description of the wound, injury or disease, and specify in what manner it has affected the applicant so as to produce disability in the degree stated], and he is thereby not only incapacitated for duty afore NAVAL-REGULATIONS AND FORMS. said, but in the opinion of the undersigned is totally [or three fourths, or one half, or one third, or one fourth, as the degree of disability may be] disabled from obtaining his subsistence by manual labor. I certify that, who was a —— on board of this ship, while under my command, and while engaged in his duty as a was, in consequence of the following circumstances, so injured as to be prevented from any further performance of his duty as a ——, and I, therefore, deem it proper that he should be discharged from the naval service of the United States. He was accordingly discharged on the day of 18-. While he was [Here state, particularly, all the facts as to the origin of the applicant's disability; the duty in which he was engaged; the particular circumstances which led to the injury, the harbor, navy-yard, river, bay or ocean, where the ship was, and the time when the injury was received.] Commander, (8) Certificate of Ordinary Disability. a- in the United States navy, I hereby certify that attached to [if at a navy-yard, ship or hospital, insert name and place], and holding the rank above-mentioned, as set forth in the record of his case, of which the following is a copy: [Here insert record made by senior medical officer], and, therefore, in the opinion of the undersigned, the interests of the service require that he should be discharged. The above-named Surgeon. was born at. in the State of is years of age; hair. of - 18-; and -feet and He entered the United States naval service at, discharged [Here insert whether final, or to hospital or inches high; complexion; eyes; ship, for passage home, in which cases the discharges must be furnished by the fourth auditor.] Approved: Paymaster [formerly Purser.] Discharged from the United States naval service, on the day of 18-. Fourth Auditor. |