
The image depicts a historical document titled "Receipt for declaration under the act of May 11, 1912," which is related to pension service and displays spaces for company, regiment, and pension certificate number details; it includes handwritten information for Company "H", Regiment "128", and a Pension Certificate No. "948674". The document is issued under the authority of J. L. Davenport, Commissioner of Pensions, and bears a stamp dated June 3, 1912, from the U.S. Pension Office. The lower section instructs the claimant to fill in personal details, showing handwritten entries of the name "John Jacobs," with an address in Van Buren, Hancock County, Ohio.