2. I desire to obtain an Order for the Reception of
________________________________________________
as a person of unsound mind, in the Haydock Lodge Licensed House,
situate at Newton-le-Willows, Lancashire.
3. I last saw the said__________________________________
at______________________________________________________
on the (g)_______day of________________ 19_______
4. I am (h)_______________________________ of the
said________________________________________________
(or if the Petitioner is not connected with or related
to the or Patient, state as follows:)
I am not related to or connected with the said_________________
________________________________________________________
The reasons why this Petition is not presented by a relation
or connection are as follows: