3

WAR RECORD

First went into action (place):

(date):

Participated in the following engagements:

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: died of disease Pneumonia.

(place): [Mousec?] france

(date): Oct 30. 1918

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:

(from):

Discharged from service at (place):

(date):

as a (rank):

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::