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[[preprinted]]
Application - Bladensburg Union. ^[[1928]]
City or Town : State : Month : Date : Year :
^[[Bladensburg Md. June 15 1893.]]
I hereby make application for admission into the Bladensburg Union.
Age last birthday ^[[(35) thirty five]] years
[[signature]] ^[[Mabel J. Mason]] [[/signature]]
Name of Applicant.
[[double line]]
This certifies that the above-named applicant is in reasonably good health.
[[signature]] ^[[Geo H Gates]] [[/signature]] , M. D. 
[[/preprinted]]