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c. dat de inzittenden van het onder a genoemde luchtvaartuig de volgende maatregelen hebben ondergaan:

Af gegeven den 19 , te ;

De burgemeester voornoemd,

Model IV. (Verklaring ten behoeve van den (Engelsch) gezagvoerder, van de Directie der Luchtvaartonderneming of van haar vertegenwoordiger.)

DECLARATION, mentioned under B of

article 25 of the Royal Decree of ,

as to the sanitary measures to which the

aircraft indicated

of nationality, its cargo

and the persons on board have been submitted in the aerodrome of

The Burgomaster of

ha ving regard to what is appointed under B

of article 25 of the Royal Decree of

ha ving seen the written report, dated .

19 , n°. , of '

hereby declares :

a. that the aircraft indicated

of nationality which arrived at

the aerodrome of , on the

day of 19 , Commander

, aerodrome of depar-

ture intermediate aerodro-

mes , next aerodrome of

destination , has been sub¬

mitted tot the following sanitary measures :

b. that the cargo of the aircraft mentioned under a has been submitted to the following sanitary measures;

c. that the persons on board the aircraft mentioned under a have been submitted to the following sanitary measures :

Delivered on the ... day

of l 19 , at

The Burgomaster,

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