3

WAR RECORD

First went into action (place):

(date):

Participated in the following engagements: Artois sector. St. mihiel Offensive. Meuse Argonne.

Cited, decorated, or otherwise honored for distinguished services (give circumstantial accounts of exploits, including dates and places where performed, also by whom and in what manner the honors were bestowed): :

Killed in action, killed by accident, died of wounds, died of disease, wounded, gassed, shell-shocked, taken prisoner:

Nature of casualty:

(place):

(date):

Nature of casualty:

(place):

(date):

Nature of casualty:

(place):

(date):

Under medical care:-

Name of hospital:

Location:

From (date):

to (date):

Name of hospital:

Location:

From (date):

to (date):

Name of hospital:

Location:

From (date):

to (date):

Name of hospital:

Location:

From (date):

to (date):

Permanently disabled (through loss of limb, eyesight, etc.) (specify disability):

Arrived at (American port):

on (ship):

Date: 6-1-1 19

(from):

Discharged from service at (place):

(date): 6-11-19

as a (rank): Ist Cl. PVT

RETURN TO CIVIL LIFE

Occupation after the war:

If a change of occupation was occasioned by reason of disability acquired in the service, describe the process of re-education and readjustment, and indicate the agencies or individuals chiefly instrumental in furnishing the new occupations::

WAR RECORD

First went into action (place):

(date):

Participated in the following engagements: Artois sector. St. mihiel Offensive. Meuse Argonne.

Cited, decorated, or otherwise honored for distinguished services (give circumstantial accounts of exploits, including dates and places where performed, also by whom and in what manner the honors were bestowed): :

Killed in action, killed by accident, died of wounds, died of disease, wounded, gassed, shell-shocked, taken prisoner:

Nature of casualty:

(place):

(date):

Nature of casualty:

(place):

(date):

Nature of casualty:

(place):

(date):

Under medical care:-

Name of hospital:

Location:

From (date):

to (date):

Name of hospital:

Location:

From (date):

to (date):

Name of hospital:

Location:

From (date):

to (date):

Name of hospital:

Location:

From (date):

to (date):

Permanently disabled (through loss of limb, eyesight, etc.) (specify disability):

Arrived at (American port):

on (ship):

Date: 6-1-1 19

(from):

Discharged from service at (place):

(date): 6-11-19

as a (rank): Ist Cl. PVT

RETURN TO CIVIL LIFE

Occupation after the war:

If a change of occupation was occasioned by reason of disability acquired in the service, describe the process of re-education and readjustment, and indicate the agencies or individuals chiefly instrumental in furnishing the new occupations::