by common name, wound, or injury.) (If by disease, state the original cause, and the time when incurred, as exactly as may be practicable. If by wound or injury, describe the same.) He is thereby not only incapacitated for duty as aforesaid, but in the opinion of the undersigned is (one-fourth, half) disabled from obtaining his subsistence by manual labor. To Commanding, United States Navy. Surgeon United States Navy. FORM NO. 28. Application for Disability Survey, from Surgeon of a Naval Hospital. U. S. NAVAL HOSPITAL, 18-. a SIR: I have to request that a survey may be held on in the United States Navy, received from the United States on the and now under treatment in this hospi tal. He is (partially or wholly) disabled, and his disability is likely to be permanent. GENTLEMEN: You will hold survey as recommended above, in accordance with the regulations under the head of Pensions, and report in triplicate. You will particularly state all facts you may be able to elicit, in regard to origin of disability, even when you do not find it to be in line of duty. Report of Survey on case of disability, to determine if cause of disability originated in line of duty. U. S. NAVAL HOSPITAL, 18-. a SIR: In compliance with your order of the we have held a survey upon in the United States Navy, now in this hospital, and have to report that he (is or is not partially or wholly) disabled, and that his disability (was or was not) incurred in the line of duty. He is disabled (one-fourth, one-half, or wholly) from [here state the particulars of disability] and his disability was occasioned by [here state the circumstances under which the disability was incurred.] Report of death, and order for board to determine if cause of death originated in line of duty. U. S. NAVAL HOSPITAL, 18-. SIR: I have to report the death, to-day, in this hospital, of in the United States Navy. He was received from the GENTLEMEN: You are hereby appointed a board to take testimony, according to regulations under the head of Pensions, in order to determine if the above-named ▬▬▬▬▬ ▬▬▬▬▬▬▬▬▬▬▬▬ was or was not in the line of his duty when (the disease was incurred, or the wound or injury was received,) which caused his death. You will report in triplicate. Report of Board to determine if cause of death originated in line of duty. U. S. 18-. SIR: In compliance with your order of instant, we have taken testimony, in order to determine if the cause of the death of a in the United States Navy, originated in the line of duty, and have to report as follows: [Here state briefly the facts elicited. as to the cause of death, and distinctly, whether or not, it originated in the line of duty.] Very respectfully, To Commanding Navy Yard. |