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

STATE OF ILLINOIS,

of..

..COUNTY.

in the county of.....

being

duly sworn, deposes and says that he is the lawful possessor of the annexed and foregoing diploma, and that he is the person therein named, that said diploma was issued to

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STATE OF ILLINOIS,

COUNTY.

being duly sworn, deposes and says that he is a resident of..

medicine, and received a diploma from..

and a graduate in

on or about the

year...

and that the said diploma has been lost, and is

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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No certificate will be issued until the fee of $1.00 is paid.

STATE OF ILLINOIS,

.COUNTY.

being duly sworn, deposes and says that he is a resident of..

*in the county of..

State of Illinois, and that he has practiced medicine and surgery in the State of Illinois, years last past (must be ten or more years

for a period of.

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If a certificate is wanted by nongraduates who have practiced medicine 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 practitioners 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.

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

STATE OF ILLINOIS.

COUNTY.

being duly sworn, deposes and says that she is a resident of

.in the county of..

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

period of.

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

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

BACK OF ABOVE.

ILLINOIS STATE BOARD OF HEALTH.

FOR MIDWIVES TEN OR MORE
YEARS IN THIS STATE.

No.

INSTRUCTIONS.

If applicant has a certificate or diploma, it must be sent to the Board for verification; if not, and she has practiced in this state ten or more years, the affidavit must be accompanied by recommendations from reputable medical men. Those without certificates or diplomas, and who have not practiced the requisite length of time in this state, must present themselves before the Board for examination. The fee for examination is $5.00.

No...

STATE BOARD OF HEALTH.

STATE OF ILLINOIS.

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

factory evidence that.

Illinois, has been engaged for..

in the State of

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

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

practice.

Given under the hands and Seal of the State Board of Health of

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