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OCR
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"
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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
Page data
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- Source index
- 0
- Type
- photo
- Media ID
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Document data
- ID
- 2661384
- Core
- doc
- Type
- document
DTO data
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Context sent to Scholar
Document identity
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Document source metadata
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Document source extras
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"month": 6,
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Page context
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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"
}