Text-book of forensic medicine and toxicology

by R. J. M. Buchanan

of (a)___________________________________________________

in the (b)_____________________ of_________________________

(c) _____________________________________________________

_______________________________________an alleged lunatic.

I, the undersigned, ________________________________________
do hereby certify as follows:

1. I am a person registered under the Medical Act, 1858,
and I am in the actual practice of the medical profession.

(d) Insert the place of examination, giving the name of the street with number or name of house, or should there be no number, the Christian and surname of occupier.

(e) County, city, or borough, as the case may be.

(f) Omit this where only one certificate is required.

(g) A lunatic or an idiot, or a person of unsound mind.