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Model C.

BILL OF HEALTH.

UNCLEAN (CLEAN) BILL.

Granted to the Master.

The undersigner , harbor-master

at hereby certifies:

a. that the port of. * in

t in

accordanrp tn ac* i®92 no. 44. , , ii,

art. 5 of the act of I902~nö7 ii2. been declared

infected as prevails there in epidemie form.

b. that the port of . has not been declared infected bij any contagious disease.

(date)

The harbor-master,

N. B. The commander of a ship, receiving this bill, if touching in any other port before his departure from the Netherlands East Indies is bound to note down on this paper the state of health of that port.

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