APPLICATION FOR ARREARS OF PENSION.
To the Commissioner of Pensions:
STATE OF NORTH CAROLINA, | SS.
Signed in my presence by Susan Ann Dove who is known to me to be the person she describes herself to be, and at the same time she exhibited to me her pension certificate, which is numbered 147996.
Wm L. Palmer
[stamped on back of document] DEPARTMENT OF THE INTERIOR. PENSION OFFICE. NOV 12 1879