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op het luchtvaartterrein van ;

6. dat genoemde reiziger aldaar de volgende maatregelen heeft ondergaan • c. dat de bagage van genoemde(n) passagier aldaar de volgende maatregelen heeft ondergaan :

Afgegeven den 19 , te

De burgemeester voornoemd,

Model V. (Verklaring voor passagiers.) (Engelsch)

No.,

DECLARATION mentioned under C of

article 25 of the Royal Decree of ,

as to the arrival of ;

passenger of aircraft indicated

of nationality and

the 8anitary measures to which this passenger his

and ; luggage hos been submitted.

The Burgomaster of ;

having regard to what is appointed under C of article 25 of the Royal Decree of ;

having seen the written report, dated

19 n° , of ;

hereby declares:

a. that passenger of

the aircraft indicated of

nationality, commander

arrived by that aircraft on the

of 19 , in the

aerodrome of ;

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

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

Delivered the ------ 1 1 day of 1—.

19 , at

The Burgomaster,

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