No. 



stamp of Issuing Office 



DOLLARS CENTS 







(Form No. 6C01i 



>dTHiRD ASSISTANT POSTMASTER GENERAU 



lea 



a DIVISION OF MONEY ORDERS 



. «The Postmaster 

 ;!2wilUnsert 



;-ohere 



^ gttie office drawn on, when tbe offioe named by 



J gtbe remitter in the body of this application Is not a Money Order Office 



*»ij ' 



J ~ Spaces above this line are for the Postmaster's record, to be filled in by him. 



9 ' — ' 



iiAppIication for Domestic Money Order 



' " Spaces below to be filled in by purchaser, or, If necessary, 



S by another person for him 



G Amount 





Dollars Cents 



^tL^oil WM,..HPRYJI.AULE, 



(Name of persou or firm for whom order is intended) 



ffi O 



g '^Whose 

 ^ "oAddress 

 >.= IS 



g'^Post 1 

 a ..Office J 



ioO 



No , Street 



PHILADELPHIA, 



State. P2n!is)f!yania- 



13 Q; 



a a 

 a o 

 "gSent by.. 



(Name of Seuder) 



Address) 

 of V 

 sender j No. Street 



PURCHASER MUST SEND ORDER AND COUPON TO PaVEE 



