(h) If the same or other facts were observed previous to the time of the examination, the certifier is at liberty to subjoin them in a separate paragraph.
(i) The names and Christian names (if known) of informants to be given, with their addresses and descriptions.
(k) Strike out this clause in case of a patient whose removal is not proposed.
(l) Insert full postal address.
2. On the_______________________ day of ________________ 19__
at (d) _______________________________________________
in the (e)___________________ of _____________________
_________________(separately from any other practitioner) (f)
I personally examined the said ___________________________________
and came to the conclusion that ____ he is (g) ____________