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33
No
Borough of Wampstead.
FORM B. Public Health Department,
Town Hall,
Haverstock Hill, N.W. 3.
19 .
Maternity and Child Welfare Act, 1918.
To
Of-
r
I beg to inform you that under the terms of their Scheme for the
supply of assisted Milk, the Borough Council are prepared to pay half the cost
of pints of milk supplied by you to Mrs
of during the weeks ending
19 .
Please, therefore, supply her with pints of Milk daily ;
collect half the cost from her, and charge the other half 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 of Health.
I hereby acknowledge having received the Milk,
Signature
INVOICE.
19 .
Total value of Milk supplied to the above-named person during the
weeks ending 19
Proportion paid by the Customer ... : :
Proportion to be paid by the Borough Council ... : :
Signature and Address of Retailer
Certified Correct,
Medical Officer of Healili. Date 19
This Order in 110 way limits the amount of Milk that may be supplied; it is only art
intimation of the quantity for which the Council will assist in the payment.