joseph sindledecker pension - application of cora nixon vanaman

8/14/2019 Joseph Sindledecker Pension - Application of Cora Nixon Vanaman

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3- 044.

APPLIOA TI ON F O R R E I M BURSE M ENT .

(This appl ic at io n , w h e n pr o p e rl v e xe c u te d b e fo re so m e offi ce r h av in g au th o r itv to ad m inis te r o at h s fo r g ener a l p ur p o se s .tshould befo rwa rd ed , to g-e th e r w ith th e p e n si o n o e rt.if to ate an d ite mi zed bi lls o f all ex p e n se s , to the C o m m is s ion e r o f P e n s io n s , W as hing ton , D. C .)

: : : : :"o:nna 1 Z :;;;~~/ n n nn..1ss ,On th is /4:_~~'__ay Of _~ --, A. D. o n e thousand n in e hund red all d, ~

p ~~y appear ed b ef o re I~:};Y;:--;",~-~----d-~-,,:,:-~-ithi n and f o r th e C o u nty an d Sta te af ore said ,

27t :~ iJt: :: .//~ ~.. .O""~YOf...... 'a: ;. ; tt : lth )jI :1 -iO J: c ,e ~ on J if e ,f .p e n s io n e r a t.t im e .o f d e ath ?(... ~ n " :wer .y e s o r ..no . ) ,._ . _ _~

7. If so, giv e th e nam e o f each c o mpa n y in w hich a p o licy w as ca rr ie d and th e amo un t in wh ic h each p ol icy was wri tten

--------------------------------------------- ----------------------- --- --- ------------------------------------- ---------------- ------------r~:;;~:t'--s~", ./"? . ,y,. -t"_________ _____ ' ' .1---- ~ _ 'l i_ _

~ r ~"-B8. Who w a s th e b eneficiar y named in eac h p o li cy? ---- - - ---- ----- --- -- -- -- - - - - -- -- - - - - - - -- -- --- -- - - --- -- -- -- --- ( ti .----l~ 5- - - -- -- -- - ----- - - -- - -- --"- --- - - -- - -- - - - - - - ---- - - --- - - - - - - - -- - - -- - - ---- - - - - -- - -, , - - - - - -- -. - - - -- - - ---- - - -- -- - - --- \ : - --- - ~f" ~

.-, . ' ' .: ' " , ., / F2 --~ < ~ .jU9 . What w a s t.he I el a tion of e ach be n c fic ia t y t.o t he p e n si o ne r . -------_--_-_?t_-_-_t_~.~_-_-_-_ -_-_-_'_'-_'_-_-_-_'_'-.-_-.-._ -,,-,,-_'_.-_ -,-_-,,-_-_-,,-_-,,-_-_._ '-_---'--- ~ _ '-,.-.,'_,_ ,_ -__ ~_(_?,.~_i;:v _ .-.j,.~-l-C.~ ;,;r.'10. 'Were the p rem ium s paid b y the dec e ase d p e n s ion e r? ,_ . , _, _ _ _ _ _ .

11 . If 11 01. p a id b y th e d ec e a sed pe ns ion e r, s ta te the am ou nt , o f pr em iu ms p a id by ea ch pe rson who m ade p ay ment , on that,

accou n t , 2 0 : : - : z : ~~ _

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Was pe n sio n er a member of any soci e ty p ay in g sick or d eat h be n efit s ? ( Answe r y es or ' no. ) ~~ .

Is t h e re a n executor o r adm ini st ra tor , o r wil l appl icati o n b e ma d e fo r a ppointment of an y p erso n a s adm ini s tr at or '! _ _~

~~ :- ~ ~~ ~ ~~ -~~~~~~~~-~-~~~~ ~ -~~~ -;~~~ ~ -~~ ~- ~-~~~ ;:-~ ~ ~ ~- ~ ~~-t~ :~ -l: ~~~ ~~ ~ ~ ;; :;~ ~ ~ ;:~ -;-~:::::~ ~ ~ ::~ - ----~- -~::: ::~ _ -~_ -_-_-_- ::: :::_- ~_ -_-_~ ~ :

1 5 . If so , state the chara c te r an d valu e o f a ll such prop erty . . _

16 . W h at was t h e assessed va lu e ( las t as sessme n t) of the r eal es ta te? h n ~ ~ C n~ -~m -~ n n --

17. H ow was th e pe nsioner's prope rty d isposed of? ~ ~ . _

;~: -~; ~ -~: ~ -~ i~:l~; -I~ ~~~-~ ~ -~ -~ .~ ~~: ~ ~~~ -~- ~~~ ~ ~ ~ ~ -:~ ~:~ -; n -(-; :~ ~~~-:~ ~ ~ -: ~ -~~:;--- -- --~ ~ ~ ~ ~g: e -- --- --~~ ~ ~: :::~_- = ::':-_-_-19. W h at was your r e lati on to th e deceas e d p e n sion er? . n . 4.._~- -21. What w~s t he ca u s~ o f p~ n slOn e~ s deat h .. ~ --~ n -n n ~ --;; ;; -~ ---- ---- ----- ~ --n~- -"--;_ ~~~ ~ ----- 7 --- -f--

2~. W he n d ld th ~ p err sro n e r s last SIckne s s b eg in .... n n .-_ -nn n :_ ~ _ y -- --n n .. n - ---- - -n- -- --n --_ 0 0 0 0 _ _0 0 _0 0 0 0

23. F rom w h at dat e did the pension er become so ill a s to require th e regula r and daily a ttendanc e o f ano th er pe rson co n stantl y

. u nt il deat h ? n n n n _ ~ _ ~ _ _~n _ _~ -----~ 7~ -- -- - [ L jL n_nn n_ nn _ _ _nn n n24. G iv e th e ~e an % t-offi ce ad dr ess of ea ch PhYSi ~ 'hO at te n d ed t h e p en sion er d u rin g las t s ick n e ss ~ n n __~

~~z~;;~~ ...q,~~.~.~~~ .=. "25. St a te the n ames of th e p erso n s by w h o m the pe n sion er was nu rsed du rin g the , pe riod o r an y po rti o n o f th e p e ri o d of la st

s ickne~ d the p eri od c ov ered by su c h ser v ice in each .in stan ce h -- -.----- --L --n ---- -nn --- ~ -- ---- -- -n -n ---- --nn-

~6::~b~~,d,;:.:~,li~~:"g~:, .:.:::::,l::~::::d:::~l::ci;;:~i~+-:* ~ -.~ . :-- -.- -'" "'"'";SO'.,.H ;as._ther~~heen_pa.id,._or~.w .illJl,p.plica.~jQ.I1..:tt e""roJ!,d.IClJor_~a,Y..J!l"(lmo_Y.


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a nd {~ _ _ _:;_r:_~ _ fZ . J ~~ , p erson s whom I c e rti fy t o b e resp ec tab le -and

~tle d to c red it , a n ~ b e in g b y m e d ul y sw o rn , say that they w er e prese~aw - ---- -- '-- --- - - -- -- -- -- - -- -- -- - -- --- - - -- --- - - -- -

_ _ _ _ __ __~~ ~7: __ ~~!: .~ ~ , the c la imant , s ign n am e (o r make ma rk )

to th e for eg oin g ap p lica tio n , a nd t h at th e y know the clai m ant there in; that they h a ve read a ll th e quest ions , an sw ers, an d

de c la ration s in sa id app li ca tio n an d be lieve th e facts therein se t fo r th t o b e t rue; and that they h ave n o inter est , di rec t o r

in d irec t , in t h is c la im,/7 ~ C L:: /J A~

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; - --.- -- -~ - - -~~ --- - - - - - --- - ------ -- ---,----- -- - --- --- - -, - -- --(s i~~i ; .~ ~n d po st-o ffi ce ad dres ses 01 w itnes se s .)'~~ ,,__ o -,"- ,__ ,- 7 - ,

B u b s cri b ed a nd sw or n to be fo re m e th is L&_:~. d '~ o f - :- -~ _ ~- --- - - -,A . D . 1 9 /1 - ; an d I ce rtify th a t th e co n ten ts of t h e fo re g o ing a pplica tio n , etc ., were f ul ly m ade kn ow n and exp la in ed to th e ,cl a ima nt and w itn esses b e fo re swea rin g, in c ludi ng th e wo rd s _

e ra se d a n d th e wo rd s , ~ add ed; .and

th at I h a ve n o in te rest , d irec t o r i n d ir ec t, in the p rose c u ti o n o f thi s c la im .

_ _ _ _ _ _ _ _ _ _; ~ ~~ ~ ; ( &__ ~_V -(O ffichd c b a l;i~~ ) ./. .

S TA T E M ENT O F A T T E N D ING P HYS ICI A NS.

- - - -- - - - - - - -- - -- - - .- . - - -- -- - - -- - - - - -- - - -- - - - - - - - - -- -- - -- - - - - -- - - - -- - - - ~ - - - - - - -- - - - - --- - -- - - - - - - - - -_ . . . - - - - - - - - - - - - - - - -- - - - - --- . - - -- - - -. - - - --- - - - ; - - - - -

G iv e na m e of e a ch p er so n w h o ren d ere d se rv ice as n u rse, and wh o has ma d e o r w ill make a c har ge for s uc h se rv ice ,

- - -- - - - -- - -- - - -- - - - - - - - --- - - - - - - - - - - - - - - - - - - - - - - - - -- - -- - - - --- --- - - ---- - -- - -- - - - _.. - - - - .. .. - -- - - - _.. - -- --_ .. - - - .. - - -- -- - - - - - - .. .. - . _.. -- - - - _.. - - - --_ .. - - ---_ .. ---. '

~ ~ ~ 'i:~W ~ O ': ~ d ~ d .th';'~ 'io ~ :m l~t ,,' k" '~ ~~~~ - ~ - : : :. :

D oes y o u r bi l l i n c lud e a c h a rge fo r a ll med ic ine fu rni sh ed t h e pe n s ioner d u r ing J as ,ts ickn es s? ~ _ , .. _

S ta te w he th e r y ou hav e read th e q u estions in the fo rego ing ap p lica tio n, and t h e c la ima n t' s a nswe rs t her e to , an d w h eth e r su c h

:__~ ~_ ~ ~ _ ~~~ _ ~ ~~ _ ~_ ~ ~~~ ~~ _ ~ ~_~~ ~ .~ _ i~ ~_ ~ ~ _ ~~ ~ ~: ~ ~ ~_ t_ ~ ~ ~ : ~ ~_~ ~ : _~~~~ ~ : ~ ~ i _ ~ ~ :_~ _ ~~_~ ;;~ :~";~~~~~ ::~~ ~~:::-_-_ -_-~ ~:~_M e nt ion a n y o th e r fa c ts w ithin yo ur kn owle dge w hic h in y ou r opin ion w o ul d b e h e lpf u l in adju s ting this cl a im fo r r e imburs em ent:

I c e r tify th a t th e fo reg o in g st a tem e nt is co rrect .

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joseph sindledecker pension - application of cora nixon vanaman

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