THE CNITED STATES, To 



Dr.. 



ON ACCOUNT OF 



Received at of 



this day of 18 



dollars cents, in full of the above account. 



(Signed in Triplicates.) 



I CERTIFY, That the above account is 



correct; that the items charged therein were required and furnished on account of the 



service above mentioned, and that the same were necessary therefor. 



