Statement of Eye-Witness

1st. How long have you known deceased? ___________________

2nd. State when and where he was injured? ___________________

3rd. What was he doing at time of injury? ___________________

4th. What was the nature of his injury? ___________________

5th. Give in detail all the circumstances attending the injury. ___________________

6th. Give in detail all the circumstances attending the injury. ___________________

6th. Give the names and post-office address-or residence-of all persons who were present at the time deceased was injured. ___________________

7th. What were you doing at the time? ___________________

8th. Was deceased under the influence of spirituous liquor at the time of his injury, or had he been drinking intoxicating liquor just prior thereto? ___________________

9th. Are you related to deceased or his beneficiary in any way, or have you any interest in the payment of this claim? ___________________

(Signature,) ___________________

STATE OF} ss:
COUNTY OF on this_______________day of_______________188

before me a __________, in and for the said County and State; personally appeared the above-named, ____________________ to me well known, and to whom I have read the foregoing questions and answers, and all the matter above stated, and who after being fully advised in the premises, subscribed the above statement in my presence, and made oath that the foregoing statements, and each and all of them are full and true, and without reservation.

Signature,

[SEAL.]

Official title, Post-Office address,

Statement of Beneficiary.

STATE OF___________________ }ss:
COUNTY OF_________________ being duly sworn, say, that is the Beneficiary named in the application of to become a member of the UNITED STATES MUTUAL ACCIDENT ASSOCIATION of the City of New York, that the said applicant, now deceased, left __________last(*) will and testament to the best of the deponent's knowledge and belief: That __________is__________year of age, and has raed the foregoing statement, and each and every part thereof; and knows the contents of the same, and that they are true to __________ own knowledge, except as to __________ in regard to which _________ has been informed: and that _____ verily believes said information to be true.

Sworn to and subscribed before me}

Signature,
this _____ day of _____ 188

Signature [SEAL.]Title of official, Post-Office address,

(*If deceased left a will. a certified copy with proof of probate, must be attached.)