Application of Soldier, Sailor, or Marine, who is on the Pension Rolls of
Virginia, classed as partially disabled, to be rerated and placed
on said Rolls under the class of totally disabled pensioners.
I, William J. Foutz, who am now on the pension rolls of Virginia, as a resident of the County of Bedford and claimed on said rolls as partially disabled, do hereby apply to be rerated and placed on said rolls as totally disabled and I do solemnly swear that since I was placed on said rolls I have become totally disabled by disease (here state the nature of the disease) – having a dislocation of my shoulder since I have been on said role in addition to my wounds and other diseases that has come on me and being seventy three years old – and that I am now permanently disabled from following any occupation for a livelihood (in case the total disability is caused by the infirmities of age, strike out all relating to disability by disease, and proceed as follows) and that such total disability is the result of the infirmities of age, which permanently disable me from following any occupation for a livelihood, and that by reason of such total disability I am now entitled to receive the sum of thirty dollars annually.
Witness my hand this 11 day of July 1905. William J. Foutz
I, James R. Foutz, a Justice of the Peace in and for the county of Bedford in the State of Virginia, do certify that William J. Foutz, whose name is signed to the foregoing application, personally appeared before me in my County aforesaid and having the aforesaid application read to him and fully explained, as well as the statements and answers therein made, the said William J. Foutz made oath before me that the said statements and answers are true.
Given under my hand this 11 day of July 1905 - James R. Foutz NP
Certificate of Physician
I, J.H. Hartwell, a practicing physician in the County of Bedford, in the State of Virginia, do certify that I am personally acquainted with William J. Foutz whose name is signed to the annexed application for rerating his pension under the act of the General Assembly of Virginia, approved December 31, 1903, and that from a personal examination of the said William J. Foutz, as to the disability set forth in his application and the cause thereof, I am clearly of the opinion that he is disabled by reason of (here state specifically the nature of the disability and the cause thereof, and if such disability be total, whether the applicant is deprived thereby of all ability to pursue his usual and ordinary occupation for a livelihood, or any other occupation for a livelihood, and if the disability be partial, to what extent the applicant is hindered thereby from pursuing such occupation as aforesaid) – By reason of his age and wounds – he is unable to use his right arm due to a dislocated and fractured shoulder (and) his jaw bone is also fractured – he is totally disabled from work. – and that I verily believe his disability is wholly due to causes assigned in the said application, and that he is entitled to aid under the provisions of the said act, and that I have no personal interest in the allowance of the applicant’s cliam.
Given under my hand, this 15th day of July 1905. J.H. Hartwell M.D.
Approval of Board of Commissioners of Pensions
I, W.D. Field, chairman of the Board of Commissioners to examine applications for pensions, do certify that the foregoing application has been examined and approved by said Board.
In testimony whereof I hereto set my hand this 9th day of February 1907