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NOTE.--No certificate will be issued until fee of $1.00 is paid in advance.

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going diploma, and that he is the person therein named, that said diploma was issue

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not now in his possession so that he can present it to the State Board of Health, as

required by the statute, in force July, 1877, relating to the practice of medicine; and

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State of Illinois, and that he has practiced medicine and surgery in the State of Illinois,

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INSTRUCTION. If a certificate is wanted by nongraduates who have practiced med. icine in this state for ten or more years before July 1, 1877, the applicant must make this affidavit, supported by evidence of good standing in a medical society, or the recommendations of reputable medical men with regard to professional character and standing. It is not obligatory that this class of practitiouers should have a certificate, but in accordance with the decision of the Attorney General of the State, the Board has the right to demand an affidavit of such length of time of practice

Unless this is done no official record of the party will be made in this office.

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NOTE.-No certificate will be issued until fee of $1.00 is paid in advance.

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State of Illinois, and that she has practiced midwifery* in the State of Ilinois for a

period of.

years last past. (Must be ten or more years before July 1st, 1877.)

Subscribed and sworn to before me, this...

day of.

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*If applicant has certificate or diploma, the name of school and date can be inserted.

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No.....

STATE BOARD OF HEALTH.

STATE OF ILLINOIS.

This Certifies, that the State Board of Health of the State of Illinois has received satis

factory evidence that.

of the County of

in the State of

Illinois, has been engaged for..

....... in the Practice of Medicine in this State, and that he is legally authorized, under the provisions of the “Act to regulate the l'rac

tice of Medicine in the State of Illinois," approved May 29th, 1877, to continue such

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