Herewith is a copy (furnished by the Commissioners in Lunacy) of the statement sent to them of the reasons for its dismissal. Signed________________________________________ ________________ 19________ Note.--_This Copy is to be obtained from the Commissioners in Lunacy by the Petitioner at his own expense._ An Order for Reception of a Lunatic is to be obtained upon a private application by Petition to a Judge of County Courts, or Stipendiary Magistrate, or Metropolitan Police Magistrate, or specially appointed Justice of the Peace. The petition is to be presented, if possible, by the husband or wife, or by a relative (_i.e._ a lineal ancestor or lineal descendant, or lineal descendant of an ancestor not more remote than great-grandfather or great-grandmother) of the Lunatic, and is to be accompanied by a Statement of Particulars and two Medical Certificates on separate sheets of paper. One of the Medical Certificates accompanying the Petition must, if practicable, be by the usual Medical Attendant of the Lunatic; if not by him, the reason must be stated (see Form above). If a previous Petition has at any time been dismissed, the facts relating to its dismissal are to be stated in the fresh Petition (see Form above); and the Petitioner must obtain from the Commissioners in Lunacy a Copy of the Statement sent to them of the reasons for its dismissal, and present this copy with his Petition. The Reception Order (which will not remain in force for more than seven days after its date), the Petition, the Statement of Particulars, and the Medical Certificates must be sent to the Superintendent or Proprietor of the Asylum, Hospital, or House where the Patient is to be received. [Sidenote: (_a_) _Insert residence of patient._ (_b_) County, city, _or_ borough, _as the case may be._ (_c_) _Insert profession or occupation, if any._ (_d_) _Insert the place of examination, giving the name of the street with number or name of house, or should there be no number, the Christian and surname of occupier._ (_e_) County, city, _or_ borough, _as the case may be._ (_f_) _Omit this where only one certificate is required._ (_g_) A lunatic _or_ an idiot, _or_ a person of unsound mind. (_h_) _If the same or other facts were observed previous to the time of the examination, the certifier is at liberty to subjoin them in a separate paragraph._ (_i_) _The names and Christian names (if known) of informants to be given, with their addresses and descriptions._ (_k_) _Strike out this clause in case of a patient whose removal is not proposed._ (_l_) _Insert full postal address._] 53 Vict. c. 5.--Sched. 2, Form 8. CERTIFICATE OF MEDICAL PRACTITIONER In the Matter of_________________________________________ of (_a_)_____________________________________________________ in the (_b_)_____________________ of_________________________