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l! is hereby certified, tha. satisfactory proof has been exhibited before the T-- for the county of--in the State of---- by the affidavits of---and--- who are persons entitled to credit, thal----- -and- d---ar the only surviving ! children of----who was a-------iR the United States service.

 in testimony whereof ! have ses

 my hand and seal of office this

 day of---ln the year----