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[[image - pair of hands in handshake]]

[[preprinted]]
Application Blank - Bladensburg Union
I hereby make application for admission in the Bladenburg Union.
Name ^[[Flossie M. White]]
Street ^[[4244 Clay St. N.E.]] City or State ^[[Washington D.c.]]
Age last birthday ^[[49]] Month ^[[December]] Year ^[[1898]]
Beneficiary ^[[Marion Odessa White]]
1. Voucher [[signature]] ^[[John G. Walker]] [[/signature]]
2. Voucher [[signature]] ^[[Ida S. Burke]] [[/signature]]
[[double line]]
This certifies that the above-named applicant is in good health.
^[[$5.00]] [[signature]] ^[[Edwin L. Williams S.]] [[/signature]] M. D. 
[[/preprinted]]