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Commanding Officer [blank] Co. [blank] Regiment : Sir, I have the honor to make application for "authority to appear before one of the medical examing boards now established by law," to be examined and retired, in accordance with an act of Congress ... approved, February 17th, 1864, and published in General Orders, no. 34 ... having been "permanently disabled in the service of the Confederate States and in the line of duty," by-- (here sta[t]e the cause of disability ... how long you have been absent from your company, &c.) [blank]

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