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3—014.

ACT OF FARAGARRS A100taY il, 1912 #?
DECLARATION FOR PENSION.

THE PENSION CERTIFICATE SHOULD NOT BE FORWARDED WITH THE APPLICATION.

State of --Michigan

County of ----Ingham o
On this. .... D4 day of .May ° ____...., A. D. one thousand nine hundred and twelve... -
personally appeared before me, a N otary Public within and for the county
and State aforesaid, _.. Kiwin_.R...Havens , who, being duly sworn according to law,
declares that he is _7Q-.-. years of age, and a resident of _.._ Lansing aS
county of Ingham , State of _... Michigan - and that he is the
identical person who was ENROLLED at __.Buchanan ,-Michig pan | under the name of
Edwin_k. Havens on the L2tN day of .. September 1g 62

asa... privates . in. G0.

P hee

= Musteredas-Sergeant,--at.-Grand-. paueyny SOME Gokebis 35, 1068-

in the service of the United States, in the civil war, and was HONORABLY DISCHARGED
(State name of war, Civil or Mexican.)
at ____Fort--Leavenworth,--Kansas------ , on the ..1§th.. day of -.... December-------------- » 18.65

That he also served __@5 Second Lieut of Co, "I" said 7th Regt Mich, Cav,

(Here give a complete statement of all other services, if any.)

—— from June..24,-.1865-t0--date-of Muster.out-of-Regtt

complexion, light ; color of hair, br own ; that his occu-

pation was clerk | ee he was born .__ May 25, ,1s%2_,
an Stafford, Geneses Co., New York

That his several places of residence since leaving the service have been as follows:...Watervlist,. Mich
June, 1866 to Jan.1,1881; Berrien Springs, Mich, Jan.1,1841 10 June

(State date of each change, as nearly as possible. ‘

Leds sf anesy 1lle, Wis. June 1505.10 d- an'y 16683. pausing, mich, since,

That he is........a pensioner. That he has... heretofore applied for pension ...numbe?r _________-
890, 831

(If a pensioner, the certificate number only need be given. If not, give the number of the former application, if one was made. )
That he makes this declaration for the purpose of be 7 Da, on the pen roll of the United
States under the provisions of the act of Habsseaytyt90" hn hi engiga voll of fs
A
That his post-office address is -.__- Lansing 227 unty of . Ingham

Charhe Lbb) wy ne (Claimant's signature in full.) NS
_ . Mey cov |

Byes y ih WN voxana U2 anuten. patil in, :
and Dosa Y, eadine in

certify to be neg an Wn credit, and whos g by me, me uly sworn, say th
present and aw a oe .. Qranat a. the claim

to the foregoing Gdrara- th thts ave every reason to believe,from the appearance of the claimant

and their acquaintance with him of _- eh years and _ 7 /___.. years, respectively, that he is the identical
person he represents himself to beast that they have no interest in the prosecution of this claim.

Vik
\\2 Ais a i a a VALbiasare Loth et,
HOA Chalas TOU dulhucle.

Lan . nee / (Signatures of witnesses. )

SUBSCRIBED and sw ry t¥ before me this i day of. 43.182,
and’ I Hereby certify that the contents of the Ybove vote iavation, etc., were fully
made known and explained to the applicant a witnesses before swearing,
including the words , erased,
and the veya. .......---——----------n-n-n-n-n-nnnn nent , added;

tI rw o interest, direct or indirect, in the prosecufion of t is claim.

Ct4ay

mare : ro JACK

| “A 2 | Commission SON.
yee S. Omen Mei Keby ae
: 7 (Official cha 25 eby, 15. 1653
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