Form No. 107, prepared by the Provost
Certificate of Discharge because Physically
To all whom it may concern:
This certifies that the person
named herein was called for the military service of the United
States by his Local Board, and reported at this camp and was
physically examined on the 22nd day of May, 1918, by Navy E. S.
Bullock M. R. C., and the said Medical Officer having found that
Louis West, Elkader, Iowa, whose Serial Number......was
physically deficient and not physically qualified for military
service; he is therefore hereby discharged from liability to
serve under the present call for military service of the United
States made by his Local Board.
This certificate is issued subject to all the
limitations and conditions of the Act of Congress approved May
18, 1917, and of all the Rules and Regulations prescribes there
under, amongst which are:
1 - It shall not continue when a cause therefore no longer
2- It may at any time be revoked, withdrawn, or modified by his
local Board, so as to render such person liable for military
service or it may be renewed.
3- The person to whom it is issued shall immediately report in
person and shall notify his board of ---
(a) The discontinuance of the cause for the issuance of this
(b) Any change which might modify in any way the cause of his
4- Upon receiving notice that this certificate has been revoked,
withdrawn, modified, or renewed, the person to whom it is issued
shall at once present it in person to his Local Board and
5- A failure to report in person or to give notice as herein
required, or conform to any of the conditions hereof will be
sufficient ground for the immediate revocation and withdrawal of
This certificate may be affirmed, modified, or withdrawn in
accordance with the decision of Local Board having jurisdiction.
Command of Capt. Robert B. Pike
Lt. 126th M. G. Bn.
E. S. Bullock, Major, M. R.
(Signature of first
(Signature of second
Dated 28 day of May, 1918.
Filed May 16th, 1919, at
10:30 o'clock a. m. Freda Katschkowsky