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[[obscured]] Slanks in these Three Columns to be filled by Shipper. The form of Invoice on the other side to be used.

|Five Coloumns|
|[[obscured]] 40.]
[[obscured]] Certificate.
[[obscured]] undersigned, Deputy-Consul-General [[obscured]] States, do hereby certify that, on [[obscured]] _day of ___________, A.D. 190, [[obscured]] described in the indorsement hereof was [[obscured]] to me by the signer of the annexed declaration. [[obscured]] further certify that I am satisfied that the person [[obscured]] the declaration hereto annexed is the person he represents himself to be, and that the actual market value or wholesale price of the merchandise described in the said invoices in the principal markets of the country at the time of exportation is correct and true, excepting as noted by me upon said invoice, or respecting while I shall make special communication to the proper authorities.
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Witness my hand and seal of office the day and year aforesaid.
Received the equivalent of $2.50 in gold. 
[[?]]
Deputy United States Consul-General, London, England.|

|Directions.
1. Full names of Deponent.
2. Address.
3. 'Purchaser of "Seller"
4. Date.
5. Port
6. Signature of Deponent.|

|[Form No. 138.]
Declaration of Purchaser or Seller.
I, 1 Hans Velten the undersigned, of 2 OBACH & COMPY 168, New Bond Street, W.
do solemnly and truly declare that I am 3 Seller
of the merchandise in the within invoice mentioned and described; that the said invoice is in all respects correct and true, and was made at L O N D O N, whence said merchandise is to be exported to the United States; that said invoice contains a true and full statement of the time when, the place where, and the person from whom the same was purchased, and the actual cost thereof, price actually paid or to be paid therefor, and all character thereon: that no discounts, bounties or drawbacks are contained in said invoice has been or will be furnished to any one, and that the currency in which said invoice is made out is that which was actually paid or is to be paid for said merchandise.
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I further declare that it is intended to make entry of said merchandise at the port of 5 New York (in bond for Detroit) in the United States of America.
Dated at L O N D O N, this 8th day of December, 1905.
6 Hans Velten.|

|PURCHASED BY IMPORTER.
Invoice No.}25926 
(leave blank.)
Here mark the forms "Original," "Duplicate," & "Triplicate" respectively: Duplicate
Issued in}[[strikethrough]] Triplicate [[/strikethrough]] Quadruplicate.
Consulate-General of the United States,
at
London, England.
Date December 8th, 1905
Sellers
Address OBACH & COMPY 168, New Bond Street, W.
Purchaser C.L. Freer Esq
33 Ferry Avenue, Detroit Mich
Name of vessel SS ST Paul.
Port of Shipment, LONDON.
Port of arrival Detroit, Michigan
Port of entry New York (in bond for Detroit)
Value£ 100.15 
Contents 1 [[?]] in 1 [[?]] Frame|

|LONDON, ENGLAND.
CUSTOM-HOUSE INDORSEMNET.*
No.
Importer
Vessel
From
Arrived
Kind of Entry:
Marks, Quantity, and Contents:
*Consular officers will leave all of above indorsement blank. It is to be filled in only at the custom house at the port of entry.|