Page:United States Statutes at Large Volume 44 Part 3.djvu/615

 PAN AMERICAN SANITARY ` CONVENTION; Novahaa i` 14, IDM. 2047 IN'I’I§RNATIONAL_BTANDARl)p  BILUOF   f Bm¤¢¤••¤¤· — -»   U '( ` imirros GONUU (_ it l  ¤i'@ IVESSJ A ’ O ,,,,,,M*·=··* O · °· ‘ 1;;-: ...... ; .... ;-;--.’.;;--i.Q ....   title)-; .... lg; .............. (the person authoriiéd tofssué the bill, at the port of ................ ;...,,---) do hereby state that the vessel hereinafter-named clears (or leaveslfrom the gut of ................................ under the following Mame of vessel ............................. ;.€gi_nationa1ity;.‘--.°-;;.’J .... gis:---ffgi'§g;§f.'.'fZf.`ff.Qii§i§L`6fi§és1 ¤:§».é.-.ZZZZIffffIfZfZ _ e ......... .--• go;aws,’_ y" cers.,.;.;,;--· .... • families,,.-,,.. ....... ., Passenprs   for.? ...... Q ....   ..=.r-: Embarklng at this port ............. ;--. 'FIrst,ed:in.r-i ...... ;-l.ls;¤•ond; eabln.-.;.-.ll-,tl,;-.i,;--;   ................. Total number or passen- ierson botgdm,- .V,,..,. .... l---, ......... ,-..-.-. orts vlsi withlgm pmseumg four montbs--;- ; ............................ nm ```' Eéi ol-vessel ``'`   `1§{i»6§£I»$££i-ijZ1`.'.`.Z`.'.`.`.'.`.ZZ`.Z`.`.Z`.ZZ`.ZZZ'.`.`.}`éiii ‘¤?’ ‘·‘· passe ‘·‘·‘‘‘‘‘‘‘‘‘‘‘‘‘ m "i"“°°° $‘?.é"...i‘£i°.a ‘··‘‘·‘‘·· s ‘.;r.i.,· 1....., ‘‘‘‘ an ngers or mem, o crew on aecoun state zlisease ........................................................... Time vessel was in port (date and hour of arrival) .......................... ; (date and hour of departure) ..........., ................................. ter of communication with shore ......... - ........................ .. Sanitary condition of vessel .............................................. Sahita.? measures, if any, adopted while in port .............. .. ............. Date o last fumigation or the destruction of rodents ....................... Number of rodents obtained ............................................. Port where fumigated ........................... and odicials supervising the fumigation .......... .. .................................................. Method of iumigation used (for rodents) .................................. ; (for mosquitoes) ................ . ....................................... INFORMATION CONCERNING THE PORT Hsdthdvwt- Sanitary conditions of port and vicinity ............... - ................... Prevailmg diseases at port and vicinity .... - ............................... Number of Cases and  the Following Named Diseases During the Two Weeks ing .................... (Any c¤ndltl::M the vm m...... &"2¤"‘..;"i‘· ..¥'B?.E» t?%‘.‘“»..r.°“’.».t.¤"“‘§“ "‘° "°“ °‘ Yellow Fever ...... .. ..... - ....... - ....... Asiatic Cholera .......... - ....... - ....... Cholera nostras or eholerine ........ - ....... Smallpox ............... - ....... - ....... mu Fever ........... - ....... - ....... e- ..,............. - ....... - ....... Leprosy ................ - ....... - ....... Health Oilioe of the Port of ..................................... . (When Eiactieable this eertillcate should be signed by the Health Ollicer of the Port) te of last case of: . Cholera .................................................. ; ......... §eIlow Fever ....................................................... uman Plague. ...............,. - ................................... Typhus ............................................................ Rodent Plague ................. 4 ................................... - Measures, if any, imposed by the municipality against rats during the last six months ............................................................. '`'`'` §¢gno¢' ```` Ji J5} F£»2`Er2£i¢i`6`p¤w ````````` (¤Whenthsr•ere¤o¤asescrdeaths,entrytothateiIJectm¤stb•mads.)

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