Receipt for Supplies - Springfield Fire and Marine Insurance Company

Front:
1018-D. --- -- -- ------ RECEIPT FOR SUPPLIES Vesta, Nobe l Agency ------ ----- Agent Shipped APR. 5. 1910. via. Luulda Express Co., Charges Paid Received of the Springfield Fire and Marine Insurance Company the following ------ Commission --------- Register, with Prohibited List Attached ----Sign --- ---------Loss Reports * Fire Policies--- -inclusive * Tornado Policies...- Linclusive Dwelling Policies ---------to--- -inclusive Comb. F. & T. Policies ------ inclusive Auto Policies F. & T.- inclusive -inclusive 10.0#78898 Certificates ---inclusive ---- --_to__ Received. Athule qu014 a leare Rulles Age Rece Please verify, Sign and mail to us at once. Do not use Rubber Stamp or Typewriter for Signature

Back:
OENTS SISKE Springfield Fire and Marine Insurance Co. 134 SOUTH LA SALLE STREET CHICAGO, ILL.