Form No. 6001 



POST OFFICE DEPARTMENT 



THIRD ASSISTANT POSTMASTER GENERAL Stamp o? Issuing Office 



DIVISION OF MONEY ORDERS ' 



The Postmaster 

 will insert 



here 



the office drawn on, when the office named by . 



the remitter in the body of this application is not h Money Order Office. 



Spaces above this line are for the Postmaster's record, to be filled in b; him 



Application for Domestic Moaey Order 



Spaces below to be filled in by purchaser, or, if necessary, 

 by another person for him 



Amount 



Dollars Cents 



SeSerV} F^W^OLQIANO & CO.. 



(Name of jtersoa or ijnu lor whom order is in tended) 



Whose ) 

 Address >^ 



is J No Street 



Post 

 Office. 



} WASHINGTON. 



state -,-fv^- 



Sent by 



(Naaie cl eender) 



Address] 

 of [ 

 sender J No. Street 



PURCHASER MUST SEND ORDER AND COUPON TO PAYEE 



c6— 7166 



