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2. FOR CASES OF MANIA-A-POTU.

MEDICAL CERTIFICATE.

——— 186 .

I hereby certify, that ——— is insane with mania-a-potu,
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 promise to
pay to the President and Visitors thereof, at said Hospital, in
bankable funds, weekly in advance, the sum of ———— dol-
lars a week for medical attendance and for board, until said
patient is removed 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 when discharged, and
to pay for funeral expenses in the event of death.

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

I request that the said ———— shall be admitted into the
Maryland Hospital; and in consideration of his being so ad-
mitted, I hereby guarantee the performance of the above ob-
ligation.

———— Surety.

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