2. On the _____________ day of _____________ 19 ____
at (d) ____________________________________________
in the (e) ________________ of ______________________
I personally examined the said ________________________
and came to the conclusion that ______ he is (f)___________
and a proper person to be taken charge of and detained under
care and treatment.
3. I formed this conclusion on the following grounds, viz.:—
(a) Facts indicating Insanity observed by myself
at the time of examination (g), viz.:—
______________________________________________
______________________________________________
______________________________________________
______________________________________________
(b) Facts communicated by others (h), viz:—
______________________________________________
______________________________________________
______________________________________________
______________________________________________
(i) If an urgency certificate is required, it must be added here.—Form No. 9.
53 Vict. c. 5.—Form 9.
(i) STATEMENT ACCOMPANYING
URGENCY ORDER