slave proceeded under said impressment to the city of Richmond, and was then employed by the authorities of the Confederate States, under the Engineer department to labor on said defences, at or near said City, until or about the 11h day of December 1862, when he died of disease contracted while thus employed as labourer in the service of the Confederate States, as [weh?] also [adknow?] by certificate hereto attached. Your [?] further states that he has received no compensation for the loss of said slave, and in no wise [?] his title thereto now claims for compensation for the loss aforesaid, and he therefore prays that he may be awarded compensation for the full value of said slave.
Sworn to, and subscribed before me a Justice of the Peace in and for said County and State, this ___ day of ____ 1865
Justice of the Peace