(Form No. G001) 
■post ©Sin? Separtmrnt N0._ . 
THIRD ASSISTANT POSTMASTER GENERAL Stamp 0? issuing Office. 
the remitter in the body of this application is not a Money Order Office. 
Spaces above this line arc for the Postmaster's record, to be filled in by him. 
Application for Domestic Money Order 
Spaces below to bo filled In by purchaser, or, If necessary, 
by another person for him 
Amount 
.Dollars.Cents 
Order*of) Peter Henderson & Go. 
(Nam* of penon or firm for whom order It intended) 
Whose ) 
Address* 
is ) No. 
35 & 37 Cor.tlandt Rfro ., 
Post ) 
Office) . 
New York 
State . N. Y. . 
Sent by. 
V 
(Nam* of Sender) 
Address) 
of 
Sender ) No.. .Street 
PURCHASER MUST SEND ORDER AND COUPON TO PAYEE 
