Receipt for Supplies

Front:
1018-D. RECEIPT FOR SUPPLIES MR.I.F.HALL, AGENT, 5413 ---- Agency SPRING RANCH , ------ Agent Shipped ---- via ------NEBR. ----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.- -inclusive Dwelling Policies. _inclusive Comb. F. & T. Policies. ----- inclusive Auto Policies F. & T.---- inclusive 16 ----Tornadoto_Riders inclusive Certificatos -inclusive ---- ------ 19 Received ------- ------- Agent Please verify, sign and mail to us at once. Do not usedobber Stamp or Typewriter for Signature

Back:
RECEIVE CS S116 S.IY.INS.CO. Springfield Fire and Marine Insurance Co. | 209 WEST JACKSON BOULEVARD CHICAGO, ILL.