(a) Name of
Patient.
(b) Name
of asylum,
hospital,
licensed
house,
or single
charge.
(c) Justice
of the
Peace
for ——,
or Judge of
County
Court
of —, or
Stipendiary
Magistrate
for ——
I, the undersigned, hereby state that a former Petition for
Reception of (a)___________________________________________
into (b)__________________________________________________
was presented to __________________________________________
(c)______________________________________________________
in the month of________________ 19_______, and dismissed.
Herewith is a copy
(furnished by the Commissioners in Lunacy)
of the statement sent to them of the reasons for its dismissal.