
Form 6001 | 
POST OFFICE DEPARTMENT No 
THIRD ASSISTANT POSTMASTER GENERAL 
DIVISION OF MONEY ORDERS Stamp of Issulng Office 
ee ewe ee nee oeon 
The Postmaster 
will insert 
MORO Sao 2a oe oe ee ee ee 
the ofles drawn on, when the office 
named by-the remitter does not trans- 
act money-order business 
Spaces abeve this line 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— 
T RES, 
Ne Se Mar bore pi Stas (oe eae a Bes NS aes Cents 
To be VAN BOURGONDIEN Bros., Inc.. 
paid = sere (QName of person or firm for whom order is intended) _ 
ay eaep Pe ge a ee 
address} P. 0. BOX 925 
gS 9 eee Se ee ee ce) ee Se ee enece Street 
hy 
an 
State ____..___ BABYLON, L. I, N. ¥ 5 ee ee 
ICED EV tig ae ep ipl eae pare eg ie Pe an eo 
(Name of sender) 
AR i gS AE ae 5 a IS SSN a ae a a Sa Street 
City 
and 
Stdtepeestore seers os. iat nie eee ee aoe eS San eee eal. 
PURCHASER MUST SEND ORDER AND COUPON TO PAYEE 
(FOR FEES SEE OTHER SIDE) 016—8391-2 
