10

Reproduced at the National Archives

[3-010 a.]
Act of June 27, 1890.

AA DECLARATION FOR INVALID PENSION. AA

To be executed before a Court of Record or some officer thereof having custody of its seal, a Notary Public or Justice of the
Peache, whose official signature shall be verified by his official seal, and in case he has none, his signature and official character
shall be certified by a Clerk of a Court Record, or a City or County Clerk.

Terr [strikethrough] State OF New Mexico
County of Santa Fe
ss.

On this 29 day of May , A.D. one thousand eight hundered ninety-four
personally appeared before me, a United States Commissioner
within and forut eh county and Terr aforesaid, Newton Jackson
aged (about) 55 years, a resident of the City of Santa Fe
county of Santa Fe, Terr of New Mexico, who, being
duly sworn accordign to law, declares that he is ith identical Newton Jackson
who was ENROLLED on the 17th day of March, 1864, in Co. D. 18
[Here state rank, company and regiment
Regiment, U.S. Calfred Infantry, Vals, as a private
in Military service, or vessel, if in the Navy.]
in the service of the United States in the War of the Rebellion, an served at least ninety days, and was HONOR-
ABLY DISCHARGED at Huntsville Alabama on the 21st day of February
1866 That he is, by reason of Hernia, unable to earna support by manual labor by
reason of Hernia. or rupture of teh boweles
[Here name the disease or injuries from which disabled.]
That said disabilites are no due to his vidious habits, and are to the best of his knowledge and belief of a
permanent character. That he has not applied for pension heretofore
[strikethrough] That he is a pensioner under Certificate No. ___
[If a pensioner, ther Certificate number only need be given. If not give the number of the
former application if one was made [end of strikethrough]

That he has not been employed in the Military or Naval Service otherwise than as state above.
That he makes this declaration for the purpose of being placed on the pension roll of the United States
under the provisions of the Act of June 27, 1890.

He hereby appoints [illegible] Cyrus Bussey.
of Washington, District of Columbia, his true and lawful attorney
to prosecute his claim and receive a fee of $___. That his POST-OFFICE ADDRESS is Santa Fe
county of Santa Fe, Terr of New Mexico
Newton X Jackson
[claimant's signature.]
marker

Attest: (1) N. L. Fievele
(2) Juan Ortiz y Rodriguez

14138-10, 000. 6-589