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This is to certify, that ⸻ ⸻, a native of ⸻, and a resident of ⸻, color ⸻, years of age, ⸺, sex ⸻, has produced satisfactory proof to me that ⸺ has had yellow fever or is acclimated to it by long residence in towns and cities where it has prevailed in recent years, that ⸺ is protected from smallpox by successful vaccination or a previous attack of the disease, and that ⸺ is in good health at the present time.

And I further declare my belief that ⸺ is sufficiently acclimated to the diseases of the tropics, so that ⸺ presence threatens no danger from yellow fever, cholera, or smallpox.

[Form 17.]

Havana, Cuba, ⸻ ⸺, 189—.

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S. Rep. 1263⸺2