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NARA 734

Form 7.

We, the subscribers, do hereby acknowledge to have received, at   of   , the sums set opposite our names, being in full of our services for the time herein expressed, having signed duplicates hereof.  

[[15 Columned Table]]
| No. | Names. | Occupation. | Period of Service. From - | period of Service. To - | Rate of Pay. Dolls. | Rate of Pay. Cents. | Total Amount Due. Dolls. | Total Amount Due. Cents. | Stoppage. Dolls. | Stoppage. Cents. | Amount Received. Dolls. | Amount Received. Cents. | Signatures. | Witness. | 
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |

| 14 | Charles Perry | Nurse | Aug 1"/66 | Aug 31"/66 | 10 | 00 |   |   | 10 | 00 | 10 | 00 | Charles Perry his x mark | Geo. S.H. Hussey Jr. |

| 15 | Emma Jacson | Cook | Aug 1"/66 | Aug 31"/66 | 10 | 00 |   |   | 10 | 00 | 10 | 00 | Emma Jackson her x mark | Geo. S.H. Hussey Jr. |

| 16 | Sally Lloyd | Cook | Aug 1"/66 | Aug 31"/66 | 10 | 00 |   |   | 10 | 00 | 10 | 00 | Sally Lloyd her x mark | Geo. S.H. Hussey Jr. |

| 17 | Elizabeth Rains | Cook | Aug 1"/66 | Aug 31"/66 | 10 | 00 |   |   | 10 | 00 | 10 | 00 | Elizabeth Rains her x mark | Geo. S.H. Hussey Jr. |

| 18 | Sally Killingsworth | Laundress | Aug 1"/66 | Aug 31"/66 | 10 | 00 |   |   | 10 | 00 | 10 | 00 | Sally Killingsworth her x mark | Geo. S.H. Hussey Jr. |

| 19 | Eliza Rodford | Laundress | Aug 1"/66 | Aug 31"/66 | 10 | 00 |   |   | 10 | 00 | 10 | 00 | Eliza Rodford her x mark | Geo. S.H. Hussey Jr. |

| 20 | Hilta Houston | Laundress | Aug 1"/66 | Aug 31"/66 | 10 | 00 |   |   | 10 | 00 | 10 | 00 | Hilta Houston her x mark | Geo. S.H. Hussey Jr. |

| 21 | Caroline Battle | Laundress | Aug 1"/66 | Aug 31"/66 | 10 | 00 |   |   | 10 | 00 | 10 | 00 | Caroline Battle her x mark | Geo. S.H. Hussey Jr. |

Approved
D.M. White
Lt. A.A.Q.M.

I certify that the above Receipt Roll is correct and just,
Geo. S.H. Hussey M.D.
A.A. Surg. in charge Howard Hospital

Approved and payment ordered,
[[strikethrough]] Col. 64th U.S.C.I. [[/strikethrough]]
Ass't Commissioner Freedmen's Bureau, State of Miss.