Fulton Co. GA  File type: CW Pension Application JACOBS, James W

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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
----------------
Page 2

                          Declaration for Pension
                          Act of May 1, 1920
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 in (<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)
---------------
Page 3

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.
---------------
Page 4

                   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
----------------
Page 5

                               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
---------------------
Page 6

                        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.
--------------
Page 7

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.
-----------------
Page 8

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
------------------
Page 9

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        Amount
West Side Funeral Home       Funeral expenses         unpaid               $100.00
902 Bankhead Av              Burial expenses          unpaid                 15.00
Atlanta, GA                  Transportation expenses  unpaid                 10.00
J Woodrow PRUITT                                            Total expenses $125.00
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Page 10

         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
--------------------
Page 11

         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
------------
Page 12

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               
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
------------
Page 13

     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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Page 14

              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 ot have occurred on the date and hour stated above.  The principal cause of death and related causes of importance in the order ofonset and duration of each:
      1. fracure of left humeru, 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.
----------------
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 - Mch 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
------------
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
--------------
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
----------------
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
-----------
Page 20

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
-----------
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
  4. Name of veteran - James W JACOBS

Submitted by Etta Stone, Adjudicator           
Approved by James E Madden, Authorizer

Noted 12-5-34  H.P.