1934 30

FORMS FOR CERTIFICATES AND OBLIGATIONS.
1. FOR THE INSANE IN GENERAL.

———186 .

MEDICAL CERTIFICATE!.

I hereby certify that —— is insane, and ought to be placed
in a hospital for the insane.

———— Physician.
Physician's P. 0. Address ————

OBLIGATION.

In consideration of ———— being admitted a patient into
the Maryland Hospital, at Baltimore, at my request, I prom-
ise to pay to the President and Visitors thereof, at said hos-
pital, in bankable funds, quarterly in advance, on the first
days of January, April, July and October with interest after
said days respectively, the rate of ——— dollars a week for
medical attendance, and for board, until said patient is re-
moved by me from said hospital, and I promise also to pay
for or to provide all requisite' clothing and other things
deemed proper for the health or comfort of the said patient,
— to receive or to remove (him or her) when discharged, —
and to pay for funeral expenses in the event of death.

Witness my hand this ——— day of———186 , at ——

I request that said ———— shall be admitted into the Mary-
land Hospital; and in consideration of (his or her) being so
admitted, I hereby guarantee the performance of the above
obligation.

——— Surety.
To be signed by a citizen of Baltimore.

Baltimore, ———

N. B.—The first pre-payment will bo made for the ttime
from the date of admission "to the 31st of March, or the 30th
of June, or the 30th of September, or the 31st of December,
When a patient is discharged, or dies, before the time paid
for has expired, a balance will be placed to the credit of his
account.