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van nationaliteit, den

19 aangekomen op het

luchtvaartterrein van

gezagvoerder : ,

luchtvaartterrein waar de reis is aangevangen

luchtvaartterrein van tusschenlanding

, volgend luchtvaartterrein van

bestemming »

de volgende maatregelen hebben ondergaan :

Af gegeven den; , 19....:..., te

De burgemeester voornoemd,

Model III. (Verklaring ten behoeve van eige(Engelsch) naars van lading en van andere goederen.)

DECLARATION, mentioned under A of

article 25 of the Royal Decree of

as to the 8anitary measures to which the cargo and other goods of the aircraft indica-

ted of

nationality in the aerodrome of

have been submitted.

The Burgomaster of

ha ving regard to what is appointed under A of article 25 of the Royal Decree of ;

ha ving seen the written report, dated

19 , n° of ;

hereby declares :

that the cargo and other goods of the aircraft

indicated of

nationality, which arrived on the

day of 19 in the aerodrome of

Commander aerodrome of de-

parture intermediate aerodro-

mes next aerodrome of

destination have been submitted

to the following sanitary measures:

Delivered on the day of

_ 19 , at 1

The Burgomaster,

*

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