(_c_) _______________________________________________________ _______________________________________an alleged lunatic. I, the undersigned, ______________________________________________ do hereby certify as follows: 1. I am a person registered under the Medical Act, 1858, and I am in the actual practice of the medical profession. 2. On the_______________________ day of ________________ 19__ at (_d_) _______________________________________________ in the (_e_)___________________ of _____________________ _________________(separately from any other practitioner) (_f_) I personally examined the said ___________________________________ and came to the conclusion that ____ he is (_g_) ____________ and a proper person to be taken charge of and detained under care and treatment. 3. I formed this conclusion on the following grounds, viz.:-- (_a_) Facts indicating insanity observed by myself at the time of examination (_h_), viz.:-- _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ (_b_) Facts communicated by others (_i_), viz.: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 4. The said __________________________________________________ appeared to me to be[18]..................in a fit condition of bodily health to be removed to an asylum, hospital, or licensed house (_k_). 5. I give this certificate having first read the section of the Act of Parliament printed below. =Signed=____________________________________ of (_l_)_____________________________ =Dated= this __________ day of ________ 19__ [18] _Or_ not to be. [Sidenote: Lunacy 8. 53 Vict. c. 5, ss. 4, 11, 16, 28, 29.] _Extract from section 317 of the Lunacy Act, 1890._ Any person who makes a wilful misstatement of any material fact in any medical or other certificate or in any statement or report of bodily or mental condition under this Act, shall be guilty of a misdemeanour. [Sidenote: (_a_) A Justice for --, specially appointed under the Lunacy Act, 1890, _or_ the Judge of the County Court of --, _or_ the Stipendiary Magistrate for-- (_b_) _Address and occupation._ (_d_) _Name of petitioner._]