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Form 11.

Roll of Soldiers employed on extra duty as Cooks and Nurses in the Hospital at

185—, by

, Surgeon.

during the month of

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I certify that the above is a correct roll of the enlisted men employed on extra duty, under my direction, during the month of 185, and that the remarks opposite their names are accurate and just. Examined: Commanding.

Surgeon.

Form 12.

ARMY OF THE UNITED STATES.

(Coat of Arms.)

at

Certificate of Disability for Discharge. A. B., of Captain -'s company (-), of the

regiment of United States was enlisted by

of the regiment of

day of

to serve years; he was born in in the State of

is

years of age, feet inches high, complexion, eyes, hair, and by occupation when enlisted -- During the last two months said soldier has been unfit for duty

days.

on the

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(The company commander will here add a statement of all the facts known to him concerning the disease or wound, or cause of disability of the soldier; the time, place, manner, and all the circumstances under which.the injury occurred, or disease originated or appeared; the duty, or service, or situation of the soldier at the time the injury was received or disease contracted, or supposed to be contracted; and whatever facts may aid a judgment as to the cause, immediate or remote, of the disability, and the circumstances attending it.)

C. D., Commanding Company.

When the facts are not known to the company commander, the certificate of any officer, or affidavit of other person having such knowledge, will be appended.

I CERTIFY that I have carefully examined the said of Captain

's company, and find him incapable of performing the duties of a soldier, because of (here describe particularly the disability, wound, or disease; the extent to which it deprives him of the use of any limb or faculty, or affects his health, strength, activity, constitution, or capacity to labor or earn his subsistence). The surgeon will add, from his knowledge of the facts and circumstances, and from the evidence in the case, his professional opinion of the cause or origin of the disability.

E. F., Surgeon. (Duplicates.)

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TAKEN SICK OR RECEIVED INTO HOSPITAL DURING THE QUARTER.

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