Page 1
1 of 2
The National Archives
Cert No 1205307
Pensioner: Mary E, widow of
Veteran: James W JACOBS
Can no. 70206 Bundle 8
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Declaration for Pension The Pension Certificate should not be forwarded
with the application
State of Georgia County of Fulton ss: On this Sept 23 1922, personally
appeared before me, a Notary Public within and for the county and State
aforesaid, Fulton Co, GA, who , being duly sworn according to law,
declares that he is 84 years of age, and a resident of Atlanta county of
Fulton, State of Georgia; and that he is the identical person who was
enrolled at Casey County, Liberty Kentucky, under the name of James W
JACOBS, on the 12th day of October 1861 as a private in Company C in
39th Company C (<this is not a typo - ZP) in the service of the United
States, in the Civil War and was honorably discharged at Louisville, KY on
the 15th day of Sept 1865. That he also served ____(left open)____
That his personal description at enlistment was as follows: Height - 6
feet 1 inch; complexion - fair; color of eyes - grey; color of hair -
dark; that his occupation was - farmer; that he was born Casey County 1838
at Liberty, KY.
That he requires the regular personal aid and attention of another person
on account of the following disabilities: Yes. Heart trouble, asmar (sic),
bronical trouble (sic).
That since leaving the service he has resided at Louisville and
Shepherdsville and Atlanta, GA and his occupation has been farmer. That he
has this day applied for pension under original No. 553, 816. That he is a
pensioner under Certificate No. 1907587.
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 May
1, 1920.
(1) Thomas JOHNSON James x W JACOBS 1 Savannah St 23
Savannah St
(2) F T JOHNSON 6 Savannah St
Two attesting and identifying witnesses
Subscribed and sworn to before me this 23rd day of Sept A.D. 1922 and I
hereby certify that the contents of the above declaration were fully made
known and explained to the applicant before swearing, including the words:
sworn to and subscribe before erased, and the words: me this 23rd day of
Sept 1922 added; and that I have no interest, direct or indirect, in the
prosecution of this claim. Fred A KENT 90 Carroll St, Atlanta
Notary Public Fulton County, Georgia
My commission expires August 29, 1926.
Stamped: U S Pension Office Sep 25 1922
Stamped: Declaration accepted as a claim under Sec 2, act of May 1, 1920.
Chief, Law Div.
(note: where it states that words were changed on form, they are actually
handwritten by the notary, instead of actually having been changed - ZP)
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Act Approved May 1, 1920
Declaration for Pension
Stamped: Received Record Division Sep 27, 1922
Instructions This form is only to be used by or in behalf of one who
desires to claim original pension or under section 2 of the Act of May 1,
1920, because he requires the regular personal aid and attendance of
another person. The declaration and testimony in suppport thereof should
be executed before some officer authorized to administer oaths for general
purposes.
Act Approved May 1, 1920
Section 2 reads as follows: That every person who served ninety days or
more in the Army, Navy or Marine Corps of the United States during the
Civil War, and who has been honorably discharged therefrom, or who, having
so served less than ninety days, was discharged for a disability incurred
in the service and in the line of duty, or is now upon the pension rolls
as a Civil War veteran, and every person who served sixty days or more in
the War with Mexico, or on the coast or frontier thereof, or en route
thereto, during the war with that nation, and was honorably discharged
therefrom, and who is now, or hereafter may become, by reason of age and
physical or mental disabilities, helpless or blind, or so nearly helpless
or or blind as to require the personal aid and attendance of another
person, shall be entitled to and shall be paid a pension at the rate of
$72 per month.
Information Required
If applicant claims that, by reason of age and physical or mental
disabilities, he is helpless or blind, or so nearly helpless or blind as
to require the regular personal aid and attendance of another person, he
should file in support of his application. 1. The sworn statement of the
attending family physician, describing the disabilities which make
necessary the regular personal aid and attendance of another person. 2.
The sworn statement of the claimant's attendant showing the character and
frequency of the aid and attendance rendered; whether the claimant is
confined to the house or to his bed, and if so, whether for the whole or
only a portion of the time; and the relationship existing between the
attendant and claimant. 3. The claimant should state whether any member of
his family rendered miilitary or naval service in the late World War, and
if so, whether he has applied to the War Risk Insurance Bureau for
compensation, or is in receipt of the same because of the death in, or
since the service, of such member of his family.
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Act June 27, 1890
Certificate No. 553816 Departement of the Interior
Name Jas. W. JACOBS Bureau of Pensions Washington, D.C., January
15, 1898
Sir: In forwarding to the pension agent the executed voucher for your next
quarterly payment please favor me by returning this circular to him with
replies to the questions enumerated below.
Very respectfully, M Clay EVANS, Commissioner
James W JACOBS
Donansburg, Greens Co., KY
First. Are you married? If so, please state your wife's full name and her
maiden name.
Answer. Euphama LILI
Second. When, where and by whom were you married?
Answer. Munfordville. John JAMES. Jan 28, 1873
Third. What record of marriage exists?
Answer. Munfordsville, Hart Co., KY
Fourth. Were you previously married? If so, please state the name of your
former wife and the date and place of her death or divorce.
Answer. Mary G FORD died 1869 ill.
Fifth. Have you any children living? If so, please state their names and
the dates of their birth.
Answer. Vernory JACOB - Aug 26, 1875; Sary A - Sept 11, 1878;
Alford - July 5, 1881; Maty J - Jan 5, 1884; James W - Feb 10, 1887; Mary
H - Feb 27, 1890; O P JACOB - Oct 11, 1893; Josey E - July 17,
1896.
Date of reply: May 4, 1898 James W JACOBS Signature
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Department of the Interior Bureau of Pensions Washington, D.C., January 2,
1915
Sir: Please answer, at your earliest convenience the questions enumerted
below. The information is requested for future use, and it may be of great
value to your widow or children. Use the inclosed (sic) envelope, which
requires no stamp.
Very respectfully, G M Saltzgaber, Commissioner
Stamped: U S Pension Office Apr 15, 1915
No. 1 Date and place of birth? Answer. Liberty, Casey Co., KY The name of
the organizations in which you served? Answer. Company C 27th Regiment and
Company C 29th Regiment
No. 2 What was your post office at enlistment? Answer. Liberty, Kentucky
No. 3 State your wife's full name and her maiden name. Answer. Euphamah
JACOBS. Her maiden name Euphamah LILE.
No. 4 When, where and by whom were you married? Answer. Munfordville, Hart
Co., KY 27th day of January 1873.
No. 5 Is there any official or church record of your marriage? Married by
John JAMES Baptist minister. If so, where? Answer.
No. 6 Were you previously married? If so, state the name of your former
wife, the date of the marriage and the date and place of her death or
divorce. If there was more than one previous marriage, let your answer
include all former wives. Answer. We were married at Jerome STRADER'S
in Hart County Kentucky. I have been married since to Mary E BURREDTT
(sic) who is my present wife. I married her in Jeffersonville, Indiana May
20, 1900.
No 7 If your present wife was married before her marriage to you, state
the name of her former husband, the date of such marriage, and the date of
death and place of his death or divorce, and state whether he ever
rendered any military or naval service, and if so, give name of the
organization in which her served. If she was married more than once before
her marriage to you, let your answer include all former husbands. Answer.
She was never married before.
No. 8 Are you now living with your wife, or has there been a separation?
Answer. I am now living with my second wife - who was Mary E BURNETT.
No. 9 State the names and dates of birth of all your children, living or
dead. Answer.
Nora J JACOBS - born August 25, 1874
Laura A JACOBS - born Sept 12, 1877 dead
Alfred J JACOBS - born July 15, 1880
Mary H JACOBS - born Feb 27, 1890
James Wood JACOBS - born Feb 10, 1885
O P JACOBS - born Oct 11, 1892
Josie E JACOBS - born July 19, 1895
Mattie JACOBS - born Jan 5, 1883 dead
Date April 3, 1915 (Signature) James x W JACOBS
Attest: C P BRADBURY
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Declaration for Widow's Pension Act of September 1, 1922 General Pension
Act Civil War, War with Spain, Philippine Insurrection and Chinese Boxer
Rebellion
State of Georgia, County of Fulton, ss. On this 30 day of April 1923,
before me, the undersigned, personally appeared Mary E JACOBS, who
makes the following declaration as an application for pension under the
provisions of the Act of Congress Approved General Pension for the Civil
War. That she is 63 years of age, that she was born on May 26th, 1859 at
Bulloch (Bullitt?)County Kentucky. That she was formerly the widow of
James W JACOBS, who enlisted on 1st June 1865, at ____(left
open)____ under the name of James W JACOBS in Co C 39th Regiment Ky
Inft. and was honorably discharged Sept 15th 1865 having served ninety
days or more, or died in service, or was discharged for a disability
incurred in service and line of duty in the Army, Navy or Marine Corps of
the United States during the War with Spain, the Chinese Boxer Rebellion,
or the Philippine Insurrection between April 21, 1898 and July 4, 1902,
and who died March 19th, 1923 at Atlanta, Georgia. That he also served in
____(left open)____ and that, except as herein stated, said soldier
(sailor or marine) was not employed in the military or naval service of
the United States:
That she was married to said soldier (sailor or marine) on May 10, 1900
under the name of Mary E BURNETT, by Benjamin T NIXON, JP at
Clark County, Indiana; that she had not been previously married, that he
had __(open)__ been previously married; That she was not divorced from the
soldier (sailor or marine); that after his death she remarried to __not__
at ____(left open)____ who died on ____(left open)____ at ____(left
open)____; or that she was divorced from him without fault on her part on
____(left open)____; that he did ____ serve in the Army, Navy or Marine
Corps of the United States. That she did not marry again after the death
of the soldier (sailor or marine) except to ____(left open)____. That the
following are the only children of the soldier (sailor or marine) who are
now living and are under the age of sixteen years of age: All children
over 16 years of age. That she has not heretofore applied for pension, the
number of her claim being ___(left open)___; that said soldier (sailor or
marine) was a pensioner, the number of his pension certificate being
553816. That she hereby appoints with full power of substitution and
revocation Jno P HAUNSON, Atlanta, GA her true and lawfull
attorneys, to prosecute this claim, and receive therefor legal fee.
Two attesting witnesses:
Josephine FEIL? Mary E JACOBS
502 Connolly Blvd 23 Savannah St Atlanta, Georgia
Mrs Dora HARMON
21 Tennessee Ave.
Subscribed and sworn to before me this 30 day of April 1923 and I hereby
certify that the contents of the above declaration were fully made known
and explained to the applicant before swearing, including the words xxx
erased and the words xxx added; and that I have no interest, direct or
indirect, in the prosecution of this claim. W J LANEY Notary
Public, Fulton Co., GA 525 Connally Bld., Atlanta, GA
Stamped: U S Pension Office May 2, 1923
Stamped: Attorney File Law Division
Stamped: Declaration accepted as a widow's claim under Act of May 1, 1920.
Power of attorney valid as to execution. Chief, Law Div.
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JACOBS
May 4, 1923
General Pension of Civil War (typewritten, possibly by notary)
Act of September 1, 1922 (crossed out and changed to - Act of May 5, 1923)
War with Spain, Chinese Boxer Rebellion and Philippine Insurrection
Declaration for Widow's Pension
Claimant: Mary E JACOBS
Soldier: Private James W JACOBS
Service: Co C 39 KY Inft. This is only to be used by or in behalf of a
widow or a soldier (or sailor) who remarried and is again a widow, or who
has been divorced from subsequent husband or husbands without fault on her
part, who desires to claim pension under the act of September 1, 1922, on
account of the service of an officer or enlisted manwho served ninety days
or more in theArmy, Navy or Marine corps during the War with Spain,
Chinese Boxer Rebellion or the Philippine Insurrection. Declaration must
be executed before some officer authorized for general purposes. If usch
officer is not required by law to have and use a seal, his official
character, signature, and term of office must be certified by the proper
State, county or city ___cer under his official seal unless a certificate
has been issued in the Bureau of Pensions for general reference.
Filed by Jno P HAUNSON, Atlanta, Ga.
The Act of September 1, 1922 Widow's The act of September 1, 1922, grants
pension to the widow of an officer or enlisted man who served ninety days
or more in the Army, Navy or Marine Corps of the United States during the
War with Spain, the Chinese Boxer Rebellion, or the Philippine
Insurrection between April 21, 1898 and July 4, 1902 and was honorably
discharged from such service or regardless of the length or service was
discharged for or died in service of a disability incurred in service and
inline of duty, upon due proof of her husband's death, without regard to
the cause of death, provided their marriage took place prior to September
1, 1922. Income is not a factor. The act grants pension to a former widow
of an oficer or enlisted man who rendered service as above described,
whether she remarried once or more than once, if it be shown that each
subsequent or successive marriage has been dissolved either by death of
the husband or by divorce without fault on the part of the wife, provided
her marriage to the person on whose service she claims took place prior to
September 1, 1922. Income is not a factor. The rate of pension for either
a widow or a remarried widow entitled under the act is Twenty Dollars per
month, with Four Dollars per month for each minor child of the soldier,
sailor or marine under sixteen years of age at the date of filing
application. Fees The legal fee in claims under this act is Ten Dollars
for prosecuting claims for "original" pension, which fee is legally
payable only on the order of the Commissioner of Pensions to the agent or
attorney of record at time of allowance. No fee whatever in claims for the
automatic increase provided for therein.
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James W JACOBS
Co C 27 and Co C 39 KY Inf
Co G 6th KY Cav
Stamped: W & D Claims Service Received Nov 13, 1934
Claim for Accrued Benefits due a Deceased Beneficiary under Title I,
Public Act No. 2, 73rd Congress
Instructions The amount due from the United States to the deceased payee
at the time of death is not an asset of the estate of the payee.
Applicants for the payment of the amount due from the United States to a
deceased payee at the time of death will avoid delay in the payment to
them of such proceeds by stating in the application executed by them on
the second page of this from the following facts: 1. Applicant should
state his relationship to the intestate and, in addition - (a) Whether
deceased left surviving any widow, child under sixteen; if so, giving
their names and addresses; and if any are minors, so stating and whether a
guardian has been appointed therefor, giving dates of birth of the
children under sixteen. 2. Each funeral, burial and transportation bill
must be submitted on the regular billhead of the creditor, must be fully
itemized, must show that the expense was incurred in behalf of the
decedent for his funeral, burial and transportation, and if paid, must
show by whom payment was made. If a bill is unpaid, claim should be made
by the creditor. 3. Duplicate claims must be made by each person having a
share in the amount due. 4. Mail application and bills to the Veteran's
Administration, Washington, D.C.
Penalties Provided in Public Act No. 2, 73d Congress
Section 12. "That whoever in any claim for benefits under this title or by
regulations issued pursuant to this title, makes any sworn statement of a
material fact knowing it to be false, shall be guilty of perjury and shall
be punished by a fine of not more than $5,000 or by imprisonment for not
more than two years, or both."
Section 13. "That if any person entitled to payment of pension under this
title, whose right to such payment under this title or under any
regulation issued under this title, ceases upon the happening of any
contingency, thereafter fraudulently accepts any such payment, he shall be
punished by a fine of not more than $2,000 or by imprisonment for not more
than one year, or both."
Section 14. "That whoever shall obtain or receive any money, check or
pension under this title, or regulations issued under this title, without
being entitled to the same, and with intent to defraud the United States
or any beneficiary of the United States, shall be punished by a fine of
not more than $2,000 or by imprisonment for not more than one year, or
both."
Section 15. "Any person who shall knowingly make or cause to be made, or
conspire, combine, aid or assist in, agree to, arrange for, or in any wise
procure the making or presentation of a false or fraudulent affidavit,
declaration, certificate, statement, voucher, or paper, or writing
purporting to be such, concerning any claim for benefits under this title,
shall forfeit all rights, claims and benefits under this title, and in
addition to any and all other penalties imposed by law, shall be guilty of
a misdemeanor and upon conviction thereof shall be punished by a fine of
not more than $1,000 or imprisonment for not more than one year, or both."
Stamped: Received Nov 5, 1934 Mail sub-div Vets Adm
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Section 16. "Every guardian, curator, conservator, committee or person
legally vested with the responsibility or care of a claimant or his
estate, having charge and custody in a fiduciary capacity of money paid,
under the provisions of this title, for the benefit of any minor or
incompetent claimant, who shall embezzle the same in violation of his
trust, or convert the same to his own use, shall be punished by a fine not
exceeding $2,000 or imprisonment at hard labor for a term not exceeding
five years, or both."
Part I. - To be filled out by person paying funeral, burial and
transportation bills or rendering such service I am the son of James W and
Mary E JACOBS who died at Bankhead Ave & Simpson St on Oct 29/34.
Funeral, burial and transportation expenses were incurred as per itemized
bills herewith, and have not been paid. $34.00 Thirty four dollars has
been paid $13.00 of this amount paid by son, $21.00 paid by friends. List
below bills, in aggregate, covering funeral, burial and transportation
expenses:
Name of creditor Nature of expenses Paid or unpaid
mount
West Side Funeral Home Funeral expenses unpaid ô100.00
902 Bankhead Av Burial expenses unpaid 5.00
Atlanta, GA Transportation expenses unpaid 0.00
J Woodrow PRUITT Total expenses $125.00
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All Claimants must sign the following claim
Claim is hereby made for any accrued benefits which may be found to be due
me under Title I, Public Act No. 2, 73rd Congress
Pontanoss? JACOBS - claimant son, Pantamoss? JACOBS -
creditor, or relationship to dec. veteran Address: 631 Etheridge St
Atlanta, GA
State of Georgia}
County of Fulton} ss Subscribed and sworn to before me at Atlanta, GA this
second day of November, 1934. Sarah HUFF, Notary Public
All claimants must sign the following duplicate claim (for Comptroller
General's files)
Claim is hereby made for any accrued benefits which may be found to be due
me under Title I, Public Act No. 2, 73rd Congress
Witnesses to signature by mark:
(1) Ray W ELLINGTON Pantonoss JACOBS 600 Griffin St
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Application for Reimbursement This form not to be used if the deceased
pensioner left a widow or minor children under sixteen years of age.
State of ______}
County of _____} ss On this 21 day of Nov, A.D. 1934 before me, the
undersigned, personally appeared J WOODROW PRUITT (mgr of Westside
Funeral Home), aged 21 years, a resident of Atlanta, County of Fulton,
State of GA, who makes the following declaration as an application for,
and claim is hereby made for, reimbursement for the accrued pension for
expenses paid (or obligation incurred) in the last sickness and burial of
Mary E JACOBS, who was a pensioner of the United States by
certificate WC-1205307 and who died Oct 29, 1934 at Simmons St & Bankhead
Av and was buried at Crest Hill, East Point, GA. That the answers to
questions propounded below are full, complete and truthful to the best of
my knowledge, information and belief and that no evidence necessary to a
proper adjustment of all claims against the accrued pension is suppressed
or withheld.
1. What was the full name of the deceased pensioner? Mary E JACOBS
2. In what capacity was decedent pensioned? Widow
3. If decedent was pensioned as a soldier or sailor -
a. Was he ever married?
b. How many times and to whom?
c. If married, did his wife survive him? d. If so, is she still living? No
e. If not living, give full names and dates of death of all wives.
f. Was he ever divorced? No
g. If so, is the divorced wife still living? No
h. If not living, give her full name and the date of her death.
4. Did pensioner leave a child under 16 years of age? No
5. Is any such child still living? No
6. Were any sick or death benefits paid on pensioner's account?
If so, give name of society and amount paid. $34.00 Community doantion to
son, P JACOBS.
7. Was there insurance (life, accident or health) in force on life of
pensioner at time of death? No
8. If so, give name of each company in which a policy was carried and the
amount in which each policy was written. None
9. Who was the beneficiary named in each policy? None
10. What was the relation of each beneficiary to the pensioner? None
11. Were the premiums paid by the deceased pensioner? None
12. If not paid by the deceased pensioner, state the amount of premiums
paid by each person who made payment on that account. None
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13. Is there an executor or administrator, or will application be made for
appointment of any person as administrator? No
14. Did the deceased pensioner leave any money, real estate, or personal
property? None
15. If so, state the character and value of all such property. None
16. What was the assessed value of the real estate? None
17. How was the pensioner's property disposed of? None
18. Did pensioner leave an unindorsed (sic) pension check? Yes, the last
check was returned by son, P JACOBS
19. What was your relation to the deceased pensioner? Son
20. Are you married? Yes
21. What was the cause of the pensioner's death? Automobile accident
22. When did the pensioner's last sickness begin? She lived about 10
minutes after she was hit.
23. From what date did the pensioner become so ill as to require the
regular and daily attendance of another person constantly until death?
None
24. Give the name and post office address of each physician who attended
the pensioner during last sickness. The interns at Grady Hospital saw her
as she was dying.
25. State the name of the persons by whom the pensioner was nursed during
the last sickness. None
26. Where did the pensioner live during the last sickness? 631 Etheridge
St, Atlanta, GA
27. Has there been paid or will application be made for payment to you or
any other person, any part of the expenses of the pensioner's last
sickness and burial by any State, county or municipal corporation? No
28. Has there been or will there be an application filed in the Veteran's
Adminstration for a burial allowance? No
The following is a complete statement of all the expenses of the last
sickness and burial of said deceased pensioner:
West Side Funeral Home $ 10.00
902 Bankhead Av Casket 100.00 20
Atlanta, GA Embalming 15.00 = 125.00 Paid by P JACOBS 34.00 Balance
due $ 91.00
West Side Funeral Home - claimant 902 Bankhead Av, Atlanta, GA by J
Woodrow PRUITT
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Also appeared Rev W S PRUITT who being duly sworn, make the
following statement, each for himself, that they know the claimant herein
and that their answers to the following questions are true:
1. Did pensioner leave a widow or a minor child under age sixteen years
surviving? No
2. When did the pensioner die? Oct 29/1934
3. Did pensioner leave any property? If so, state its character and value.
None
4. Our means of knowledge of the above made statements made by us are: We
knew the deceased pensioner for 18 years and as active pastor of the
Baptist Church here for past 12 years. I k new he intimately.
Name: Rev W S PRUITT
P.O. Address: 896 Marietta St NW
Subscribed and sworn to before me, this 23 day of Nov 1934 and I certify
that the contents of the foregoing application were fully made known and
explained to the claimant and witnesses before swearing, that I have no
interest, direct or indirect, in the prosecution of this claim and further
certify that the reputation for credibility of the witnesses whose
signatures appear above is Rev W S PRUITT. R R DAVIS -
signature HP 12/2/37 - official character 784 Marietta St NW, Atlanta, GA
Statement of Attending Physicians
Give pensioner's name in full - Mary E JACOBS
Give date of commencement of pensioner's last sickness - October 29, 1934
>From what date did the pensioner require the regular and daily attendance
of another person constantly until death? October 29, 1934
During what period did you attend the pensioner? October 29, 1934
State nature of diseased from which pensioner died - hit by auto, died of
internal injury and shock.
Give name of any other physician who attended the pensioner in last
sickness - none
Does you bill include a charge for all medicine furnished the pensioner
during last sickness? Grady Hospital
Has your bill been paid; if so, by whom? Grady Hospital John M HANLEY
Jr, M D Grady Hospital
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Certificate of Death Georgia State Board of Health Bureau of Vital
Statistics
Registered No. 4685
1. County Fulton Militia District 1061 State of Georgia City of Atlanta
Street and No. - Cor Bankhead & Simmons St
2. Full name - Mrs. Mary E JACOBS Residence - 631 Etheridge St
3. Sex - female
4. Color or race - White
5. Single, married, divorced - married
6. Date of birth - May 26, 1860
7. Age - 74 y, 5 m, 3 d
8. a. Trade - domestic b. Industry - c. Date last worked - d. Total years
-
9. Birthplace - GA. (this is wrong)
10. Father name - Bennett
11. Father b.place - unknown
12. Mother name - unknown
13. Mother b.place - unknown
14. Informant - P JACOBS of 631 Etheridge St
15. Filed - 11/2/1934 by L THORNTON
16. Date of death - Oct 29, 1934 at 6:30 p.m.
17. I hereby certify that I attended the deceased form 10/29/34 to
10/29/34. I last saw her alive on 10/29/34, death said to have occurred on
the date and hour stated above. The principal cause of death and related
causes of importance in the order of onset and duration of each: 1.
fracure of left femur, left tibia and fibula 2. Internal abdominal injury
3. Shock What test confirmed diagnosis? clinical Was injury an accident,
suicide or homicide? Accident Signed Henry C COLLINS, M.D. Grady
Hospital
18.
19. Burial Place - Hillcrest Cem. at East Point on 11/2/34
20. Undertaker - Westside Funeral Home
Office of the Registrar of Vital Statistics for the City of Atlanta
1/30/35
Georgia, Fulton County I hereby certify that the foregoing is a true and
correct copy of the record of death number 4685 of the series of 1934 for
Mrs Mary E JACOBS as appears on file in the office of the Registrar
of Vital Statistics of the City of Atlanta. L THORNTON, local
registrar.
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Page 15
Georgia State Board of Health Bureau of Vital Statistics Standard
Certificate of Death
Registered No. 1284
1. Place of Death - County of Fulton, City of Atlanta (61 Savannah St)
2. Full name - J W JACOBS Residence No. 23 Savannah St
3. Sex - Male
4. Color or race - White
5. Single, married, widowed or divorced - Married
5a. If married, widowed or divorced, hus or wife of - Mary JACOBS
6. Date of birth - 4/28/23 (this is wrong)
7. Age - 97 y
8. Occupation - none
9. Birthplace - W. Va (this is wrong)
10. Name of father - Alpha JACOBS
11. B.place of father - W. Va (this is wrong)
12. Maiden name of mother - unknown
13. B.place of mother - unknown
14. The above is true to the best of my knowledge - Informant - Mrs H
WHIPPLE of 61 Savannah St
15. Filed 3/22/23 by L THORNTON, local registrar
16. Date of death - March 19, 1923
17. I hereby certify that I attended deceased from _____(left open)____
and that death occurred on the date stated above, at 5:40 p.m.. The cause
of death was as follows: Senility. Signed Paul Donehoo, Coroner,
M>D> 312 Flat Iron Bdg. on 3/20/23.
18. Length of residence in city or town where death occurred -
19. Place of burial, creamtion or removal - Westview 3/22/23
20. Undertaker - Harry G POOLE, address - city.
Office of the Registrar of Vital Statistics for the City of Atlanta
Atlanta, GA Sept 10, 1923
Georgia, Fulton County I hereby certify that the foregoing is a true and
correct copy of the record of Death Number 1284 of the series of 1923 for
J W JACOBS as appears on file in the office of the Registrar of
Vital Statistics of the City of Atlanta. L THORNTON, registrar.
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Page 16
War Department Record and Pension Division Washington, Nov 7, 1889
Respectfully returned to the Commissioner of Pensions.
James W JACOBS, a private of Company C 27 Regiment KY Infantry
Volunteers, was enrolled on the 12 day of October, 1861 at Campbellsville,
KY for 3 years, and is reported on 4 mos muster ending Aug 31/62 (1st on
which his name appears) absent sick: Sept & Oct/62, absent without leave;
Nov & Dec/62 name not _____?; Jany & Feby/63 absent in arrest in
Louisville, KY by mililtary authority; March & April/63 absent deserter
Dec 10/61: (Special muster ending April 10/63 absent without leave in 6 KY
Cavy), Name not ____? on subsequent rolls to June 30/64; July & Aug/64
present in arrest for desertion; So ____? to Feby 28/65: muster out roll
of Co dated March 29/65 at Louisville, KY reports him private with the
following remark: absent without leave
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Page 17
at the muster in of Co; sent home sick Dec 61: arrested & returned to Co
in June 26/64: not discharged, turned over to Post Commander Louisville,
KY for trial for desertion. Roll Co C 39 KY Infty (to which transferred)
for MAy & June/65 present, transferred from 27 KY Infty without any papers
(name not _____? on roll for March & April/65) He was mustered out with Co
Sept 15/65 at Louisville, KY as private with remark: Transferred from Co C
27 KY Infty: arrived Co C 39 KY Infty June 1/65 S.O. #76, Par 3, Dept KY:
No description list furnished. Returns prior to Feby 28/62 not on roll.
March/62 absent sick; May/62 absent sick in Adair Co., KY; Nov 12/61; June
62 absent on furlough Campbellsville, KY, Nov 15/62; July/62 absent as
home sick. This man while a deserter from this organization (27 KY Vols)
enlisted in violation of the 22d (now 50th) Article of War in Co G KY Cav,
Aug 5, 1862 and served with that Co and Regt until Jany 31, 1863, when
mustered out
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Page 18
at Benton Barracks, MO while convalescent and in hospital to enable him to
enlist in the Miss Marine Brigade by S.O 89 Dept of MO series of 1863. His
name is not borne on the records of the Miss Marine Brigade and the next
record of him is on May 10, 1864 when he was arrested by Pro. Mar., 4 Dist
KY as of Co C 27 KY Vols, upon the recommendation of a commission
appointed in accordance with instructions from the Adjutant General's
Office dated Aug 28, 1863; he was assigned and sent to the 39 KY Inf to
make good the time lost by desertion - 2 years - per S.O. 76 Hd.Qurs. Dept
of KY. May 20, 1865 This man deserted from Co C, 27 KY Vols December 10,
1861 and enlisted in this organization (6 KY Cavy) in violation of the 22d
(now 50th) Article of War. This Department cannot recognize the legality
of this enlistment nor any claim for service by reason of it. So far as
the charge of desertion from the 27 KY Vols so concerned the case is
covered by seciton 4 of the Act of Congress approved March 2, 1889.
By authority of the Secretary of War. by F C Arminouth?, Capt &
Asst Surgeon, USA
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Page 19
Department of the Interior Bureau of Pensions
So. Division
J S C Ex'r
July 15, 1889
No. 706229 James W JACOBS
Co C 27 KY Inf
Sir: I have the honor to request that you will furnish from the records of
the War Department a full report as to the service, disability and
hospital treatment of James W JACOBS, who it is claimed enlisted
Oct 12, 1861 and served as private in Co C, 27 Regt KY Inf; also in Co C
39 KY Inf from Mch 29 to Sept 15, 1865 and was discharged at place not
stated, Mch 29, 1865. While serving in Co C, 27 Regt KY Inf he was
disabled by typhoid fever in Jany 1862 at Campbellsville, KY. Sent home
had small pox resulting diseased of lungs, rheumatism, spinal affliction &
chronic bronchitis and was treated in hospitals of which the names,
location and dates of treatment are as follows: if charged with desertion
can it be removed. Very respectfully, James TANNER, Commissioner
The Adjutant General, U S Army
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So Division First Call on Adjutant General, USA
Claim No. 706229
James W JACOBS
Co C 27 KY Inf
Stamped: War Department Record and Pension Div. rec'd Aug 21 1889
Stamped: Judge Advocate Genl's Office rc'd Nov 1 1889
Stamped: U S Pension Office Nov 8, 1889
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Page 21
James W JACOBS
Atlanta, GA
553816
23 Savannah St
D__ Report - Pensioner
Department of the Interior Bureau of Pensions
Class: Act of May 1, 1920 Group 2
Disbursing Division
April 10, 1923
Check No. 8291735 $50.00
dated Apr 4 1923, Section 4
returned by postmaster with information that the
above described pensioner died March 19,1923 has been canceled.
E E Miller, disbursing clerk
Finance Division
April 10, 1923
The name of the above-described pensioner who
was last paid at the rate of $50 per month
to Mar 1 1928 has this day
been dropped from the roll because of death. O J Randall, Chief,
Finance Division
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Page 22
Veteran's Administration Stop Payment Notice
File No. WC-1205307
June 9/30
Civil War
Date November 28, 1934
From: W & D Claims Service
To: Finance Service, Dependents Accts Subdivision
Subject: Stop payment on Pension 1. Full name of payee - Mary E JACOBS
2. Effective date of action - October 29, 1934 Abstract required 3. Reason
for action - Pensioner died October 29, 1934. Name of veteran - James W
JACOBS
Submitted by Etta Stone, Adjudicator
Approved by James E Madden, Authorizer
Noted 12-5-34 H.P.