(Fcim No. yfojij 
poat department NO 
third ASSISTANT POSTMASTER GENERAL Stamp of Issuing Office. 
DIVISION OP MONEY ORDERS 
DOLLARS 
CENTS 
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 lias are for 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 0 of). Peter Henderson & Os, 
(Nfctc* of p«r»on o> fir* for whom «rd*r U ioUndri) 
Whose 1 
Address | 
35 & 37 Cortlandt 
is ) No.. 
Street 
Post \ 
Office) 
State 
Sent by. 
_Street 
PURCHASER MUST SEND ORDER AND COUPON TO PAYEE 
