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L.200. R.F. & A.L. Va. 2d V. 1867.
Bur R.F. and A.L. 
Head Qrs: 7th Sub-Dist: Va.
Lynchburg, Va June 7th/67.

Lacy R. S.
Agent &c.

Requests to be furnished by mail the within description and number of Blank forms

[[stamp]] STATE OF VIRGINIA. BUREAU OF R.F & A.L. RECD. HD. QRS. ASST. COMMISSIONER. JUN 8 1867 [[/stamp]]

Sent June 8th 1867

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