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31
No
Borough of Wampstead.
FORM A. Public Health Department,
Town Hall,
Haver»tock Hill, N.W, 8.
19
Maternity and Child Welfare Act, 1918.
To
Of.
Please supply to Mrs of
..pints of Milk daily during the weeks ending
19 , and charge the whole cost to the Borough Council.
No goods other than Milk are to be supplied to this Order. This form is to
be sent to me as soon as the milk has been supplied and the Customer's
signature obtained.
Medical Officer oj Health.
I hereby acknowledge having received the Milk.
Signature
INVOICE.
19
Milk supplied, free of cost, to the above-named person to the value of
during the weeks ending 19 t
Signature and Address of Retailer
Certified Correct,
Medical Officer of Health. Date 19 .
This Order In no way limits the amount of Milk that may be supplied; it is only an intimation
of the quantity lor which the Council will pay.