Mind], as a Patient into your House [or Hospital]. Subjoined is a Statement respecting the said A.B.

(Signed)

Name.
Occupation (if any).
Place of Abode.

Degree of Relationship (if any),

or other Circumstances of Connexion with the Patient.

Name of Patient, with Christian Name at Length.

Sex and Age.

Married, single, or widowed.

Condition of Life, and previous Occupation (if any).

Previous Place of Abode.

Religious Persuasion, so far as known.

Duration of existing Attack.

Whether First Attack.

Age (if known) on First Attack.

Whether subject to Epilepsy.

Whether suicidal or dangerous to others.
Previous Place of Confinement (if any).

Whether found lunatic by Inquisition, and Date of Commission.
Special Circumstances (if any) preventing the Patient being
examined, before Admission, separately, by Two Medical
Practitioners.

Special Circumstances (if any) preventing the Insertion of any of above Particulars.

Dated this

hundred and

To

Proprietor [or Superintendent] of

[describing the House or Hospital by Situation and Name, if any].

I

SCHEDULE (C.) Section 45.

FORM OF MEDICAL CERTIFICATE in the Case of PRIVATE PATIENTS. being a Physician or Surgeon, or an Apothe cary, duly authorized to practise as such, hereby certify, that I have this Day, separately from any other Medical Practitioner, visited and personally examined A.B., the Person named in the accompanying Statement and Order, and that the said A.B. is a Lunatic [or an insane Person, or an Idiot, or a Person of unsound Mind], and a proper Person to be confined, and that I have formed this Opinion from the following Fact or Facts; viz.

(Signed)

Dated this hundred and

Day of

Name.
Place of Abode.
One thousand eight

SCHEDULE (D.) Section 48.

ORDER for the RECEPTION of a PAUPER PATIENT.

WE, the undersigned, having called to our Assistance a Physician [or Surgeon, or Apothecary, as the Case may be], not being the Medical Officer of the Parish or Union to which the said A.B.

belongs,

belongs, and having personally examined A.B., a Pauper, and being satisfied that the said A.B. is a Lunatic [or an insane Person, or an Idiot, or a Person of unsound Mind], and a proper Person to be confined, hereby request you to receive the said A.B. as a Patient into your House or Hospital.

Subjoined is a Statement respecting the said A. B. (Signed) Name.

A Justice of the Peace for the

City or Borough of

[or an or the Officiating Clergyman of the Parish

of

Name.

Married, single, or widowed.

Condition of Life, and previous Occupation (if any).

Previous Place of Abode.

Religious Persuasion, so far as known.

Length of Time insane.

Whether First Attack.

Age (if known) on First Attack.

Whether subject to Epilepsy.

Whether suicidal or dangerous to others.

Previous Places of Confinement (if any).

I certify that to the best of my Knowledge the above Parti

culars are correctly stated.

Dated this

hundred

Το

Day of

Proprietor [or Superintendent] of

[describing the House or Hospital by Situation and Name, if any].

I,

MEDICAL CERTIFICATE.

being a Physician, or Surgeon, or an Apothecary, duly authorized to practise as such, hereby certify, That I have this Day personally examined A. B., the Person named in the Statement and Order, and that the said A.B. is a Lunatic [or, an insane Person, or an Idiot, or a Person of an unsound Mind], and a proper Person to be confined.

Dated this hundred and

(Signed)

Day of

Name.
Place of Abode.
One thousand eight

SCHE

M. F. M. F. M. F. M. F. M. F. M. F.

SCHEDULE (G. 2.) SECTION 54.

FORM of NOTICE of DISCHARGE or DEATH.

I HEREBY give you Notice, That a Private [or Pauper] Patient, received into this House [or Hospital] on the was discharged therefrom recovered

Day of

[or died therein, on the

[or relieved, or not improved,] by the Authority of

Dated this

eight hundred and

Day of

].

(Signed)

Superintendent [or Proprietor]

of

House [or Hos

One thousand

In case of Death, add "and I further certify, that A. B. was

present at the Death of the said
apparent Cause of Death of the said
by post mortem Examination (if so)] was

; and that the
[ascertained

SCHEDULE (H.) Section 59.

FORM of MEDICAL JOURNAL and WEEKLY REPORT.

WE, the Commissioners in Lunacy [or We whose Names are hereunto set and Seals affixed, being Two of the Commissioners in Lunacy, or Visitors] appointed under or by virtue of an Act passed in the Year of the Reign of Her present Majesty, intituled [here insert the Title of the Act], do hereby summon and require you personally to appear before us at in the Parish of in the County of

on

next the

Day of

at the

Hour of

in the

8 & 9 VICT.

3 M

noon of the same Day,
and

1 & 2 W. 4.

c. lxxvi.

and then and there to be examined, and to testify the Truth touching certain Matters relating to the Execution of the said Act.

Sealed with the Common Seal of "The Commissioners in Lunacy" [or Given under our Hands and Seals], this

Day of
hundred and

in the Year of our Lord One thousand eight

САР. СІ.

An Act to continue until the Fifth Day of July One thousand
eight hundred and sixty-two the Acts for regulating the
Vend and Delivery of Coals in London and Westminster, and
in certain Parts of the adjacent Counties; and to alter and
amend the said Acts.
[4th August 1845.]

WE HEREAS an Act was passed in the First and Second Years of the Reign of King William the Fourth, intituled 'An Act for regulating the Vend and Delivery of Coals in the Cities of London and Westminster, and in certain Parts of the Counties of Middlesex, Surrey, Kent, Essex, Hertfordshire, Buckinghamshire, and Berkshire, whereby the Provisions of the 'said Act were directed to be in force for Seven Years from and after the Thirty-first Day of December next after the passing thereof: And whereas an Act was passed in the First and Second Years of the Reign of Her present Majesty, intituled 1 & 2 Vict. c. ci. An Act to continue for Seven Years an Act for regulating the › Vend and Delivery of Coals in London and Westminster, and in 'certain Parts of the adjacent Counties: And whereas the last' mentioned Term of Seven Years, during which the Provisions 'contained in the said Acts were directed to continue in force, will expire on the Thirty-first Day of December One thousand eight hundred and forty-five, and it is expedient that the same 'should be continued, and that in the respects herein-after mentioned the said Acts should be altered and amended:' Be it therefore enacted by the Queen's most Excellent Majesty, by and with the Advice and Consent of the Lords Spiritual and Temporal, and Commons, in this present Parliament assembled, and by the Authority of the same, That the said Acts of the First and Second Years of the Reign of King William the Fourth, and the First and Second Years of the Reign of Her present Majesty, and all the Powers, Authorities, Directions, Provisions, Penalties, Forfeitures, Regulations, Clauses, Matters, and Things therein contained, (except such of them, or such Parts thereof respectively, as are repealed, altered, or otherwise provided for,) shall be and the same are hereby continued until the Fifth Day of July One thousand eight hundred and sixty-two; and all the Provisions, Regulations, Clauses, Matters, and Things in the said first-mentioned Act contained, to take effect at the End of the Term of Seven Years therein mentioned, or at any other Time or Times, shall take effect in the same Manner to all Intents and Purposes as if the Fifth Day of July One thousand eight hundred and sixty-two had been inserted in the said Act of the First and Second Years of the Reign of King William the Fourth, instead

Recited Acts continued, except as altered.

of the said Term of Seven Years.

6

II. And