“To the Medical Superintendent of the leper asylum ........................................... ...... at |
I ............................................ of ....................... do this ............... day of ...................... 20 ........, hereby request you to cause me to be admitted into the leper asylum at ................................... and I undertake to remain therein for the period of ........................... at least, unless sooner duly discharged, and to conform to the rules of the said Asylum and to any conditions which may be prescribed by authority of the Governor General.” |
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Applicant. |
................................. |
Witness. |
(Medical Officer or J.P.) |