(FOR INSTRUCTIONS SEE BOTTOM OF SHEET.) STATE OF MINNESOTA County of Otter Tail [ss abbreviation for sworn statement] (A.) Jermina Portz being duly sworn, says that [added in pencil is the letter â€œsâ€] he resides in the town of Elizabeth in the County and State aforesaid, that [inserted â€œsâ€]he was personally acquainted with wife B.) Mathias Portz in his lifetime, and that on or about the 8th day of January, 1873, the said Mathias Portz was frozen to death; that the deceased immediately preceding his death freezing he resided in said town, and his body has since been found dead that the casualty occurred in the town of County of Grant (see affidavit of March 20) That a team of Horses belonging to the deceased, and of the value of $150 (besides 2 head of (C.) Horses owned by him, and of the further value of $ ) died from the effects of said storm. That the age of the deceased was 52 years, and he died leaving a family of a wife and 6 children whose respective names and ages are as follows, viz: (D.) Susana aged 13 years. Maria 11 years. Mathias 7 years. John 5 years. Nicholas 3 years. Anna 8 months old The deceased died owning -----_acres of real estate, worth over and above all encumbrances, $--- and the following personal property, (not including the live stock above described as lost,) viz: --- bushels of grain worth $--- ; 2 horses worth $50 ; --- head of horned cattle worth $--- ; hay and feed worth $ 1.00 ; provisions for the family worth $ --- ; household goods and clothing worth $ ; fuel, and all other personal property of the value of $ 25.00 The family of the deceased have provisions sufficient to support them 1 day months, and fuel to last (E.) Mathias Portz is not dead, but he lost (by freezing) both of his hands. Sussana [sic] and Maria are both sick in their Heads, and getting worse every day they are allmost [sic] blind (F.) Jermina Portz Subscribed and sworn to before me, this (seal) 1st day of March 1873. Jacob Mowrin Justice of the Peace Elizabeth Town Otter Tail County Minn INSTRUCTIONS (A.) Write name of person making oath. (B.) â€œ â€œ deceased. (C.) Horses, cattle or hogs, as the case may be. (D.) Give name and age of each. (E.) If any member of the family is sick or disabled, or there are any other circumstances material to a full understanding of the case, write them out in the blank following (E.) The affidavit must be sworn to by two creditable persons, one signing on the line marked (F.) the other witnesses signing on the other side of this sheet. The persons making the affidavit, if not members of the family, should be those best acquainted with the facts. The officer administering the oaths, if he has the knowledge, and if not, the postmaster of the town, or one of the county officers who knows the facts, should then sign the certificate, endorsed on the back hereof. The affidavit, with letters giving further particulars, if necessary, should then be mailed or sent to the Governor.