페이지 이미지
PDF
ePub
[merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small]

To be forwarded to the Bureau of Equipment and Recruiting at the end of each quarter and expiration of cruise.

Name.

Date of enlistment.

Where enlisted.

Term of enlistment.

Rating.

spirt

[blocks in formation]

Descriptive list to accompany reports in cases for pensions.

FORM No. 29.

State.

[blocks in formation]

Tons.

Height.

Inches.

[ocr errors][merged small]

FORM No. 30.

Report of death, and order for board to determine if cause of death originated in line of duty'

[ocr errors]

U. S. NAVAL HOSPITAL,

184, SIR: I have to report the death, to-day, in this hospital, of

in the United States Navy. He was received from the United States

with (disease, wound, or injury), and his death was caused by

Very respectfully,

1

on the

[ocr errors]

To

[ocr errors]

Surgeon in charge of Hospital. Commanding V. S. (Navy-Yard or Station).

NAVY YARD,

18To Surgeon

Surgeon Surgeon GENTLEMEN : You are hereby appointed a buard 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. Very respectfully,

Commanding Navy-Yard.

FORM No. 31.

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

in the United States Navy, origi. nated 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,

Surgeon. Surgeon.

Surgeon. To

Commanding Navy. Yurd.

[ocr errors]

FORM No. 32.

Report of survey on case of disability, to determine if cause of disability originated in line of

duty.

U. S. NAVAL HOSPITAL,

184, 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.

day

He is, disabled (one-fourth, one-half, or wholly) from [here state the particulars of dis-
ability], and his disability was occasioned by [here state the circumstances under which the
disability was incurred].
Very respectfully,

Surgeon. , Surgeon.

Surgeon. To

Commandant Navy-Yard.

[ocr errors]

ital.

FORM No. 33.

egula

SURGEON'S OFFICE, NAVY-YARD,

18SIR: I have examined [state the name in full], who states that he was born in [name of town and State] on the

day of

18–, and find that he is (not] physically qualified to perform the duties of a [name the grade] in the Navy of the United States [if not qualified add], because he has [state the disability). I am, very respectfully,

Surgeon. Το

Commanding U. S. Naval Station.

or in

Erd.

FORM No. 31.

Commanding Officer's report of death or disability in line of duty to establish claim for pen

sion.

morde:

a

[merged small][ocr errors][merged small]

U. S.

18– SIR: I have to report the [death or disability] of

in the United States Navy, while serving under my command. The [death or disability) of the abovenamed

occurred on the day of 18– [here state where), and in the line of duty.

[Here state briefly, but clearly, the facts known to Commanding Officer, as to circumstances attending the death or wounding, or other cause of disability. When the facts are not known by Commanding Officer, give an abstract of the statement of an officer or other person having knowledge thereof. When death or disability occurs from disease alone, give the opinion of the Medical Officer as to the origin of the disease. But in all cases the Commanding Officer will distinctly state his own opinion whether the person was or was not in the line of his duty at the time of his death, or when he received the wound or injury, or contracted the disease producing his death or disability.] [Here add as may be proper.]

Ī inclose herewith the report of Surgeon as to the nature and degree of the disability (or as to the origin of disease, if necessary) in this case, and (if requisite) the statement of

in reference to the cause of death, or origin of wounds or injury, producing disability. Very respectfully, your obedient servant,

Commanding United States BUREAU OF MEDICINE AND SURGERY, NAVY DEPARTMENT. NOTE.-In all cases where testimony other than the personal knowledge of the Commanding Officer is requisite, such testimony will be taken in writing, and in triplicate. Will be signud by the officer or other person making it, and approved and forwarded by Commanding Officer with his report.

[ocr errors]
[merged small][ocr errors]

FORM No. 35.

Surgeon's report of death.

a

U. S.

184, Sir: I have to report the death of

in the United States Navy, serving under your command. He died on the day of

184, [here state where, ] of (casualty, disease,) as set forth in the record of his case, as follows:

[Here state briefly, but clearly, the facts as to cause of death; if the death has occurred from disease alone, state the original cause of disease, and the time when incurred as exactly as may be practicable.]

Surgeon, United States Navy.

To

Commanding United States

FORM No. 36.

Surgeon's report of disability.

[ocr errors]

a

[ocr errors]

U. S.

18--, Sir: I have to report that

in the United States Navy, serving under your command, is disabled by (disease 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.

Surgeon, United States Navy. Το

Commanding United States Navy.

1

FORM No. 37.

Application for disability survey, froin Surgeon of a naval hospital.

a

U. S. NAVAL HOSPITAL,

18SIR: 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 hospital. He is (partially or wholly) disabled, and his disability is likely to be permanent.

Very respectfully,

Surgeon in charge of Hospital.

To

Commandant (Navy-yard or Station.)

« 이전계속 »