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Bureau of Refugees, Freedmen, and Abandoned Lands.
THE UNITED STATES,
To ... Dr.

[[4 Columned Table]]
| 18 WASHINGTON, D.C. |    | DOLLS. | CTS. |
| --- | --- | --- | --- | 
|   | For  |   |   | 
|   |  $  |   |   | 
|   | /100 Dollars,  |   |   | 

I CERTIFY ON HONOR that the above account is correct and just ; that the [[strikethrough]] services were rendered as stated, and were necessary for the public service.[[/strikethrough]] articles have been (or will be) accounted for on my property account for --- 1869

Approved, and ordered paid.

Bvt. Maj. Gen. U.S.A., Commissioner.

Received, at WASHINGTON, D.C., this ... date of ... 18 , from Bvt. Brig.-Gen. GEORGE W. BALLOCH, Chief Disbursing Offer, ... Dollars and ... Cents, in full of the above account, by Check. No. ... on the United States Treasury, dated ... 18 .

[SIGNED IN DUPLICATE.]