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[[boxed]]
[[preprinted]]
WILL BLANK
...The Bladensburg Union...
Bladensburg, Md. 
^[[Newark N.J.  Aug, 19th]] 19 ^[[38]]

I ^[[Clementine, Parker]] hereby request that One Hundred Dollars (100.00) furnished by the Bladensburg Union upon death of an adult member for funeral expenses to be 
paid to my ^[[Ena. landen my neice]]
(Relative or Friend)
^[[Ena, landen 4 Astar St Nwk, N.J.]]
(Name or Beneficiary)
Philip Broome, Pres.
William E. Burke, Sec.
[[/preprinted]]
[[/boxed]]