Form No. 2
Application of Soldier, Sailor, or Marine for disability by Reason
of Disease or the infirmities of age.

I, George Stapleton, do hereby apply for aid under the act of the 
General Assembly of Virginia, approved April 2, 1908, entitled an 
act to aid the citizens of Virginia who were diabled by wounds
recieved during the war between the states while serving as soldiers,
sailors, or marines of Virginia, and such as served during the __
war as soldiers, sailor, and marines of Virginia, who lost their 
lives in said service, or whose death resulted from wounds recieved
or disease contracted in said service, and providing penalties for
violating the provisions of this act, and I do solemnly swear that I
am a citizen of the State of Virginia resident at Nicklesville, in
the Scott Co. of VA. in the said State, and that I have been an actual
resident of the said State for two years, and of the said city (or
county)for one year next preceding the date of this application, and
and that I was a soldier( or sailor or marine) of the State of Virginia,
in the war between the United States and the Confederate States, as
a member of( here state specifically the command and branch of service
to which the applicant belonged and the names of his immediate superior
officers)COL. BROWARDS Co. __ under Capt. Henry Kincaid of Co. A 22
Virginia Calvalry Capt. Abraham Fuller, and that I am now disabled by
disease(here state the nature of the disease and the cause from which
it resulted) Rheumatism caused by exposure during service, and that 
from the effects of such disease I am now permantly disabled from
following my usual and ordinary occupation or any other occupation
for a livelyhood( in the case of disability from the infirmities of 
age strike out all relating to disability by disease, and then proceed
as follows:) and that I am now suffering from the infirmities of age,
and permanantly incapacitated thereby from following my usual and
ordinary occupation, or any other occupation, for a livelyhood(here
state specifically the nature and character of the disability which
prevents the applicant from following any occupation for a livelyhood)
Partially disabled by stiff joints which prevent my working and that
during the said war I was loyal and true to my duty, and never at any
time deserted my command or voluntarily abandoned my post of duty
in the said service, and that by reason of such disability I am now
entitled to recieve under the said act the sum of fifteen dollars
annualy. And I do futher swear that I do not hold any national,State,
city or county office which pays me a salary or fees one hundred 
and fifty dollars per annum; nor do I recieve from any source what-
ever money or other means of support in value of the sum of one
hundred and fifty dollars per annum; nor do I own in my own right,
nor does hold in trust for my benefit or use, nor does my wife own,
nor does anyone hold in trust for my wife, estate or property, either
real, personal or mixed, either in fee or for life, of the assumed
value of five hundred dollars; nor do I recieve any aid or pension
from any other State, or from the United States, or from any other
source, and that I am not an inmate of any soldiers' home, or of
any other public institution; and I do further swear that the answers 
given to the following questions are true:
1. What is your age?  Ans 64
2. Where were you born? Ans Russell Co
3. How long have you resided in Virginia? Ans 64
4. How long have you resided in the city or county of your present
   residence? Ans 20
5. What is your usual and ordinary occupation for earning a 
   livelyhood? Ans working on farm
6. How long have you followed such occupation or employment? Ans 50
7. Have you followed such occupation or employment, or any other
   occupation or employment, within the last two years? If so, state
   when and where, and the amount of your annual income from the same.
   Ans None
8. State specifically the nature of your disability or disease.
   Ans Rheumatism
9. What were the causes which led to the disease which has resulted 
   in your disability? Ans Exposure in service
10. How long have you suffered from such disease, and when did you first
    become aware that you were afflicted with the same? Ans During War
11. With what disease or sickness did you suffer during the time 
    of your service? Ans from Rheumatism
12. Are you totally disabled because of such disease, or the infirmities
    of age, from following your usual and ordinary occupation or employment,
    or any other occupation or employment, by which to earn a livelyhood?
    If not totally disabled thereby, but only partially, state the extent
    of your partial disability. Ans. Partially disabled can work only a
    part of the time.
13. When and where did you enter the service of Virginia, or of the
    Confederate States? Ans in Russell Co.
14. In what command and service were you engaged during the war between
    the States? Ans Browards Command
15. How long were you in the service? Ans 4 years
16. When did you leave the service, and under what circumstances?
    Ans At close of war
17. If suffering from disease, state what physician or physicians have
    attended you for the same. Ans ____
18. Give the names and addresses of two or more in the service of your
    command, if any such be living, and if not, so state.
    Ans John A. Bradley Nicklesville, VA James Castle Weaksbury, VA
19. Give here any other information you may posess relating to your 
    service, or disability, that will support the justice of your claim 
    for aid. Ans Because old and disabled caused by Rheumatism and 
    exposure in the service.
20. Is there any camp of Confederate Veterans in the city or county of
    your residence? Ans None
21. Is there anyone living, the residence and address of whom is known
    to you, either comrade or otherwise, who has knowledge of your
    service, and of the cause of your disability? If so or not state.
    Ans ___

Witness my hand this 7th day June 1902
John W. Meade, a Justice of Peace, in and for the County
of Scott, in the State of Virginia, do certify that 
Geo. Stapleton, whose name is signed to the foregoing
application, personally appeared before me in my office,
aforesaid and having the aforesaid application read to
him and fully explained, as well as the statements and
answers therein made, the said Geo. Stapleton made oath
before me that the said statements and answers are true.

Given under my hand this 7th day of June 1902
                            John W. Meade J P

                  (A)
        OATH OF RESIDENT WITNESSES
We, James Castle and John A. Bradley, do solemnly swear that
we are residents of the County of Scott, in the said State,
and that we have known personally and well for 40 years,
Geo. Stapleton, whose name is signed to the annexed application
for aid under the act of the General Assembly of Virginia,
approved April 2, 1902, and that the said Geo. Stapleton, is a
resident of the said county ( or city), and is a man of good
reputation for truth and honesty, and that we have read the
annexed application and the answers to the questions therein
propounded, made by the said applicant, and verily believe
that the said applicant has been truthful in the said statements
and answers, and that from our personal knowledge the applicant
is disabled (state nature of the disability, and whether it is 
partial or total), Rheumatism, and that we verily believe the 
said applicant is justly entitled to aid under the said act,
and that we have no personal interest in the allowance of the
applicants claim. 
                                          John A. Bradley
                                          James Castle