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den Gesundheitsmassregeln unterworfen gewesen ist:

c. dass die Bagage des genannten Passagiers daselbst folgenden Gesundheitsmassregeln unterworfen gewesen ist:

Abgegeben, den 19 zu

Der Bürgermeister,

Model VIII (Verklaring voor passagiers).

(Engelsch.)

DECLARATION, mentioned under C of article 40 of the Royal Decree of 15 May 1933 (Staatsblad n°. 276), as to the arrival

of — passenger of the

ship, named and the sani-

tary measures to which this passenger and

his

r— luggage have been submitted. her

The Burgomaster of ;

ha ving regard to what is appointed under C of article 40 of the Royal Decree of 15 May 1933 (,Staatsblad n°. 276);

having seen the written report, dated

19 n°. of ;

hereby declares:

a. that passenger of the

ship, named —, and sailing unter

the flag, captain

arrived by that ship on the .... of

in the port

19 0f

at the roadstead

b. that the above-mentioned passenger there has been submitted tot the following sanitary measures:

c. that the above-mentioned passenger’s luggage there has been submitted to the following sanitary measures:

Delivered the day of 19 at

The Burgomaster,

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