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[[preprinted]]
Application - Bladensburg Union.

City or Town: ^[[Hyattsville]]
State: ^[[Md.]]
Month: ^[[9]]
Date: ^[[9]]
Year: ^[[1935]]

I hereby make application for admission into the Bladensburg Union.

Age last birthday ^[[48]] years

^[[Priscilla Johnson]]
Name of applicant
[[double line]]

This certifies that the above-named applicant is in reasonably good health.

^[[H. T. Willis]], M. D.
[[/preprinted]]