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3H SC/W-12 APPLICATION FOR CERTIFICATE IN LIEH OF LOST OR DESTROYED SEE FINGERPRINT INSTRUC- DISCHARGE CERTIFICATE OR CERTIFICATE OF SERVICE TIONS ON REVERSE SIDE INSTRUCTIONS - Regulations provide for issuance of a certi- payment of a fee of $1.50 is required for each certificate de- ficate in lieu of lost or destroyed Certificate of Discharge or sired. Remittance should be by United States Postal Money Service under honorable conditions only to the former soldier, Order, Certified or Cashier's Check made payable to the or in event of death, to the widow or widower. Any mutilated TREASURER OF THE UNITED STATES. certificate must be forwarded with this application. Advance TO: Commanding Officer, Military Personnel Records Center, TAGO DATE 4700 Goodfellow Boulevard, St. Louis 20, Missouri IDENTIFICATION OF INDIVIDUAL LAST NAME - FIRST NAME - MIDDLE INITIAL (Print or type) SERVICE NUMBER(S) LAST GRADE DoveR CathaRine S. nurse. DATE OF BIRTH Charlotteters P.S.Canada PLACE OF BIRTH ORGANIZATION PRIOR TO SEPARATION Au65 - 1885 Base 82 - Jaw tice Group. DATA ON LOST OR DESTROYED CERTIFICATE OF DISCHARGE OR SERVICE (List only the period(s) of service for which certificate in lieu is desired) DATE OF ENTRY DATE OF SEPARATION DATE LOST OR DESTROYED CIRCUMSTANCES SURROUNDING LOSS OR DESTRUCTION Dec. 1917 Capril 1919 21934" There abouts Ih just disappeared weh someother material INDICATE PERIODS OF SERVICE AND FORM NUMBERS OF SEPARATION PAPERS STILL IN YOUR POSSESSION (Including any Certifi- cate in Lieu of original certificate previously issued) None. THE FOLLOWING CERTIFICATION WILL BE MADE ONLY WHEN APPLICATION IS MADE BY FORMER SOLDIER I CERTIFY THAT THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF: SIGNATURE OF FORMER SOLDIER PRESENT ADDRESS (Number, street, city, zone and state) Calharine 5 Dover 2710 1/212th sh. SIGNATURE OF WITNESS (Or Guardian ) ADDRESS (Number, street, city, zone and state) H.A. Buchly P.O. Boy 369A. ST.Pets try - am AFFIDAVIT TO BE FULLY EXECUTED ONLY WHEN APPLICATION IS MADE BY WI DOW OR WIDOWER MARRIAGE TO FORMER SOLDIER DEATH OF FORMER SOLDIER DATE PLACE DATE PLACE SINCE DEATH OF FORMER SOLDIER I HAVE AT TIME OF DEATH OF FORMER SOLDIER WE WERE REMARRIED NOT REMARRIED DIVORCED NOT DIVORCED I DO SOLEMNLY SWEAR (Or affirm) THAT THE FOREGOING STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF: SIGNATURE OF WIDOW OR WIDOWER ADDRESS (Number, street, city, zone and state) SWORN TO AND SUBSCRIBED BEFORE AT ON SEAL SIGNATURE OF OFFICIAL ADMINISTERING OATH 1 Guardian must submit copy of orders of appointment with this application. DA FORM 1 MAR 55 214 PREVIOUS EDITIONS OF THIS FORM ARE OBSOLETE poer

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Document identity
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Document source extras
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    "ocrText": "3H\nSC/W-12\nAPPLICATION FOR CERTIFICATE IN LIEH OF LOST OR DESTROYED\nSEE FINGERPRINT INSTRUC-\nDISCHARGE CERTIFICATE OR CERTIFICATE OF SERVICE\nTIONS ON REVERSE SIDE\nINSTRUCTIONS - Regulations provide for issuance of a certi-\npayment of a fee of $1.50 is required for each certificate de-\nficate in lieu of lost or destroyed Certificate of Discharge or\nsired. Remittance should be by United States Postal Money\nService under honorable conditions only to the former soldier,\nOrder, Certified or Cashier's Check made payable to the\nor in event of death, to the widow or widower. Any mutilated\nTREASURER OF THE UNITED STATES.\ncertificate must be forwarded with this application. Advance\nTO: Commanding Officer, Military Personnel Records Center, TAGO\nDATE\n4700 Goodfellow Boulevard, St. Louis 20, Missouri\nIDENTIFICATION OF INDIVIDUAL\nLAST NAME - FIRST NAME - MIDDLE INITIAL (Print or type)\nSERVICE NUMBER(S)\nLAST GRADE\nDoveR CathaRine S.\nnurse.\nDATE OF BIRTH\nCharlotteters P.S.Canada\nPLACE OF BIRTH\nORGANIZATION PRIOR TO SEPARATION\nAu65 - 1885\nBase 82 - Jaw tice Group.\nDATA ON LOST OR DESTROYED CERTIFICATE OF DISCHARGE OR SERVICE\n(List only the period(s) of service for which certificate in lieu is desired)\nDATE OF ENTRY\nDATE OF SEPARATION\nDATE LOST OR DESTROYED\nCIRCUMSTANCES SURROUNDING LOSS OR DESTRUCTION\nDec. 1917\nCapril 1919\n21934\"\nThere abouts\nIh just disappeared weh\nsomeother material\nINDICATE PERIODS OF SERVICE AND FORM NUMBERS OF SEPARATION PAPERS STILL IN YOUR POSSESSION (Including any Certifi-\ncate in Lieu of original certificate previously issued)\nNone.\nTHE FOLLOWING CERTIFICATION WILL BE MADE ONLY WHEN APPLICATION IS MADE BY FORMER SOLDIER\nI CERTIFY THAT THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF:\nSIGNATURE OF FORMER SOLDIER\nPRESENT ADDRESS (Number, street, city, zone and state)\nCalharine 5 Dover\n2710 1/212th sh.\nSIGNATURE OF WITNESS (Or Guardian )\nADDRESS (Number, street, city, zone and state)\nH.A. Buchly\nP.O. Boy 369A.\nST.Pets try - am\nAFFIDAVIT TO BE FULLY EXECUTED ONLY WHEN APPLICATION IS MADE BY WI DOW OR WIDOWER\nMARRIAGE TO FORMER SOLDIER\nDEATH OF FORMER SOLDIER\nDATE\nPLACE\nDATE\nPLACE\nSINCE DEATH OF FORMER SOLDIER I HAVE\nAT TIME OF DEATH OF FORMER SOLDIER WE WERE\nREMARRIED\nNOT REMARRIED\nDIVORCED\nNOT DIVORCED\nI DO SOLEMNLY SWEAR (Or affirm) THAT THE FOREGOING STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF:\nSIGNATURE OF WIDOW OR WIDOWER\nADDRESS (Number, street, city, zone and state)\nSWORN TO AND SUBSCRIBED BEFORE AT\nON\nSEAL\nSIGNATURE OF OFFICIAL ADMINISTERING OATH\n1\nGuardian must submit copy of orders of appointment with this application.\nDA\nFORM\n1 MAR 55\n214\nPREVIOUS EDITIONS OF THIS FORM ARE OBSOLETE\npoer"
}