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[[boxed]]
[[preprinted]]
Will Blank
... The Bladensburg Union...
Bladensburg, Md.

^[[April 3]] 19 ^[[50]]

I ^[[Paul J. Johnson]] hereby request that One Hundred Dollars (100.00) furnished by the Bladensburg Union upon the death of an adult member for funeral expenses to be 
paid to my ^[[wife]]
(Relative or Friend)

[[signature]] ^[[Gladys W Johnson]] [[/signature]] 
(Name of Beneficiary)

Philip Broome, Pres.
William E. Burke, Sec.
[[/preprinted]]
[[/boxed]]