Form H-2
Brookline,
190
This is to certify that in my opinion
aged
.at Mr.
No.
street, is ill with
Patient is
going to
Hospital,
Milk Supply
190
(if Diphtheria, Typhoid
or Scarlet Fever),
Physician.
are the notifiable diseases: Actinomycosis, Asiatic Cholera, Cerebro-
The following
spinal Meningitis, Chickenpox, Diphtheria, Dog-bite requiring anti-rabic treatment,
Glanders, Inflammation of eyes of new-born, Leprosy, Malarial Fever, Malignant Pustule,
Measles, Scarlet Fever, Smallpox, Tetanus, Trichinosis, *Tuberculosis, Typhoid Fever,
Typhus Fever, Whooping Cough, Yellow Fever.
*Please state form
