Medical

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MEDICAL CERTIFICATE

(Signaluro oi tho applicant)

(~amo> ...... :.12.&..:... t:~:rzti:!?::)h.:_~ ..-..


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·- caretu•1 persona I alC.6mmullon
' ' o f th..o case "' t hat .. -r
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.....1\-:\..t:LP.\~t).:!}'.1.......J::l:J-i}:-!.1•.C::-.•• J. •.J. .~:. ~ ~1.t~.,~}';~ {Name and Olficia, addresa.J


lI ,oc ~~~::t-.Lh.'u!.n............"................ whosn siijn&bJtu is givcn-ebOVt! rs suffering from
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.......\(.t..~.n.\.......... f:.~~.'.t.!~-........... and thfll I c:cnt.i<icr 1ha1 a ponC>d·of o.bsun~ from
u y o~............ ,11
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.•. ~~ - ••· w1.lh •J-1r_t...~,
....... ... ~····-.. ,···• . . _ 1rom .........\~f.
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ecessary for the ,restoratton of nlei.lhar i,colth
ls absolutely r,_
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Signotura or Modl~JI Officer.•~ .:.,. _ ,, ,,.

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Reg1strauon No • -··-·····~ l"t.'i 'I. l .,.
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Fort of R,Jgistralion ....:-3.~ .. ~. 1


Staiion • .. E1.~:J..1. .r:~t~.'.:- • • • a. ■ 11 It· t ■ •• I ■ •■ 1 ■ t-

Syt,le m of Medi~·..... !~.. ~\:~t ................... .


Date ; .. J..~.f :.].l.?.~!!..~~
_......,

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