Form No. 6001 
POST OFFICE DEPARTMENT NO.- 
THIRD ASSISTANT POSTMASTER GENERAL Stamp of Issuing OIBce 
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 a Money Order Office. 
Spaces aboTe this line are (or the Postmaster’s record, to be filled in by him 
Application for Domestic Money Order 
Spaces below to be filled in by purchaser, or, if necessary, 
by another person for him 
Amount 
_Dollars_Cents 
Order of} . . THE STORRs 
(Name of person or firm for whom order ia intended) 
_ 5EEDJ5MEN,.PJLDJRlS.TJS^J^lURSER.YMEIjL _ 
Whose ] 
Address > 
Is J No_Street 
Office}_ _ P.AIJNESyiLLE_ _ 
State_ OHIO- 
Sent by__ 
(Name of sender) 
No._Street 
City I 
and > 
State) _ 
PURCHASER MUST SEND ORDER AND COUPON TO PAYEE 
o5—7155 
Name. 
St. or R. F. D. 
Post Office. 
^.State. 
THE STORKS & HARRISON CO., 
PAINESVILLE. 
Lake County, 
OHIO 
