OWE BLANK 
MA B ty. Casto PATC 
a i a ag - ee ee ents wee ee me en me eee ete 
Date 
Loe eee Se. 
Post Office ) : ig 
aerate ngage oe Oe AGd. 



Date Yanted 
ae 



t 

Size Variety 

ee a 
aw Nel a e ; ‘ ' 
H - i.  Reenee Oe 
Se eee ee + —--——  -—-—-F ; 
H i 
Ti ssl erlasiaens ania 
icapreeiee oe aa ae a fp pe ee eee 
Amount Enclosed 
ee ee eee fae eee eee = ee 
