This item is a sheet of paper that was used as a receipt for proof of purchase. The upper left corner has an illustration of teeth with blue pen markings where the fillings were. It reads: "No. 129" and some other illegible cursive writing in blue pen ink. It says, "For filling teeth with gold $10.00" The total amount is $20.00. It is dated to January 9th, 1869. The back of it reads: "Mrs. Boosinger Bill $20 $10 paid" in blue handwritten cursive. It was folded in half the long way, and then in half again 2 more times the other way. The fold marks leave 8 equal sized squares. The crease marks are discolored. The receipt is yellowed.