Showing 29 items
matching vaccination certificate
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Greensborough Historical SocietyCertificate (copy), Vaccination Certificate: William Alan Partington 1909, 04/05/1909
... Vaccination Certificate: William Alan Partington 1909....vaccination certificate...Copy of Vaccination Certificate. .... william alan partington vaccination certificate alan partington ...This certified the 'successful vaccination' of William Alan Partington, aged 4 months on 4th May 1909.An example of early documentation of public vaccination program.Copy of Vaccination Certificate. Details completed by hand and signed by Doctor.william alan partington, vaccination certificate, alan partington -
National Vietnam Veterans Museum (NVVM)Booklet - Vaccination Certificate
... Vaccination Certificate...Vaccination Certificate...WHO International Certificates of Vaccination. Issued... Newhaven phillip-island-and-the-bass-coast Vaccination Certificate ...WHO International Certificates of Vaccination. Issued to 3797419 McKenzievaccination certificate, mckenzie -
Whitehorse Historical Society Inc.Certificate - Document, Vaccination Certificate, 1864
... Vaccination Certificate...Photocopy of Vaccination Certificate for Carl Benno... Photocopy of Vaccination Certificate for Carl Benno Schwerkolt, son ...Photocopy of Vaccination Certificate for Carl Benno Schwerkolt, son of August.schwerkolt family, schwerkolt, carl benno -
Polish Museum & Archives in Australia
Document (item) - Certificate of vaccination, Certificate of vaccination for Zdzislaw Martyszus
... Certificate of vaccination...Certificate of vaccination for Zdzislaw Martyszus... Carrington Drive Albion melbourne Certificate of vaccination ... -
Bendigo Historical Society Inc.Document - LEA FAMILY COLLECTION: DOCUMENT
... Certificate of Succesul Vaccination...Certificate of Vaccination for Thomas Lea aged 6 months... PERSON Certificate vaccination certificate Lea Family Documents ...Certificate of Vaccination for Thomas Lea aged 6 months. Child of Charles Lea in Malmsbury. Public Vaccination for the District of Malmsbury.person, certificate, vaccination certificate, lea family documents, certificate of succesul vaccination, thomas lea, charles lea -
Bendigo Historical Society Inc.Document - LEA FAMILY COLLECTION: DOCUMENT
... Certificate of Successful Vaccination...Certificate of Vaccination for Albert James Lea aged 8... PERSON Certificate vaccination certificate Lea Family Documents ...Certificate of Vaccination for Albert James Lea aged 8 months. Child of Charles Lea in the Parish of Milloo. Public Vaccinator for the District of Rochester.person, certificate, vaccination certificate, lea family documents, certificate of successful vaccination, albert james lea, charles lea -
National Vietnam Veterans Museum (NVVM)Booklet - Vaccination record, C 1960
... Certificate Vaccination...International Certificate of Vaccination... Newhaven phillip-island-and-the-bass-coast Certificate Vaccination ...International Certificate of Vaccination3787397 Sell Q Lcertificate vaccination, vaccinate -
Ringwood and District Historical Society
Photographs/documents, Harris Family memorabilia - photos of house and land, wedding etc. Will of Richard Francis Harris. Death Cert of James Augustine Harris. 1960s-1980s, 1960-1980s
... ' vaccination certificate was sent to Mr. M.W. Harris, Queen Street...; Will of Richard Francis Harris; Vaccination certificate; Death certificate... Augustine Harris' vaccination certificate was sent to Mr. M.W ...Collection of the Harris family memorabilia given to Richard Carter by Judy O'Neill. Wedding groups may be James Harris' wedding. The collection of 22 photos include boring for water in the 1968 drought. The will of Richard Francis Harris gives a share to James Augustine Harris. James Augustine Harris' vaccination certificate was sent to Mr. M.W. Harris, Queen Street Bendigo. James lived in Dorset Rd Boronia prior to his death.Collection of 22 photos - 9x9 - black and white - house and land; 4 wedding photos - un-named; 3 miscellaneous photos; Will of Richard Francis Harris; Vaccination certificate; Death certificate of James Augustine Harris with his funeral arrangements and tributes -
National Vietnam Veterans Museum (NVVM)Card
... Vaccination Certificate... Meal Card 3. Yellow Certificate of vaccination All blank... Vaccination Certificate All blank and all issued by US Military Three ...Three examples of unused ration/vace cards isssued by US Military Assistance Command Vietnam 1. Pink Ration Card 2. White Meal Card 3. Yellow Certificate of vaccination All blank and all issued by US MilitaryAll blank and all issued by US Militarycards, ration card, vaccination certificate -
Eltham District Historical Society IncCertificate - Certificate of Successful Vaccination, Emily Gladys Withers, Kew, Victoria, 15 November, 1888
... Certificate of Successful Vaccination...Vaccination Certificate... Vaccination Certificate Walter Herbert Withers Digital file created ...1888, emily gladys withers, john withers collection, vaccination certificate, walter herbert withers -
Greensborough Historical SocietyDocument - Document collection, COVID-19 Vaccination information, 2021
... vaccination certificate... vaccinations received. covid pandemic vaccination certificate COVID-19 ...Collection consists of: Letter to citizens recommending COVID-19 vaccine booster from Prime Minister, Health Minister and Chief Medical Officer; Austin Health vaccine Information leaflet; two Australian Government post vaccination information leaflets; photocopied patient vaccine card and one (redacted) COVID-19 printed digital certificate listing two A-Z vaccinations received.Collection of documents relating to COVID-19 AstraZeneca vaccinations of an individual in May and August 2021covid pandemic, vaccination certificate, covid-19 -
National Vietnam Veterans Museum (NVVM)
Certificate, 12/06/1945 12:00:00 AM
... Vaccination Certificate printed on mustard coloured... Commonwealth Of Australia Vaccination Certificate printed on mustard ...Vaccination Certificate printed on mustard coloured cardboard. Signed and recorded in blue ink. Stamped by Commonwealth of Australia and dated. 4 Pagescertificate, document, commonwealth of australia -
Bendigo Historical Society Inc.Document - GERTRUDE PERRY COLLECTION: CERTIFICATE OF VACCINATION, 1917
... GERTRUDE PERRY COLLECTION: CERTIFICATE OF VACCINATION... Certificate of Vaccination Gertrude Eva Perry...Document. Certificate of Successful Vaccination... of Vaccination Gertrude Eva Perry Perry Mr. H L Document. Certificate ...Document. Certificate of Successful Vaccination of Gertrude Eva Perry April 25th 1917 in Borough of Eaglehawk. Addressed to Mr. H. L. Perry, Brown St., California Gully.organization, government, health, gertrude perry collection, certificate of vaccination gertrude eva perry, perry mr. h l -
National Vietnam Veterans Museum (NVVM)Memorabilia - Memorabilia of A Matthews
... , vaccination certificate, mess membership card Vung Tau...), r&r booklet Bangkok, postcard in envelope, vaccination ...Dog tags, Peace Medallion, air boarding pass to come home, military money (5 notes), r&r booklet Bangkok, postcard in envelope, vaccination certificate, mess membership card Vung Taupersonal items, matthews, a.r, 35 squadron, dogtag, peace sign, pendant -
Bendigo Historical Society Inc.Document - CERTICATE OF VACCINATION, 1800's
... DOCUMENT Certificate Vaccination Certicate of Successful ...Certicate of Successful Vaccination (Duplicate) , birth registered in 187? , Eaglehawk. Issued re Elizabeth Jane (Hall??). Signed by Public Vaccinator for the District (John Shaw??).document, certificate, vaccination -
Warrnambool and District Historical Society Inc.Document (Collection) - Collection of personal papers, 20th Century
... , vaccination certificates, and a cigar box made in Holland. Some..., vaccination certificates, and a cigar box made in Holland. Some ...Donation from familyPersonal HistoryItems kept in foldersPersonal Papersjonas sirtautas and fanni rosenhammerjonas sirtautas and fanni rosenhammer -
Bendigo Historical Society Inc.Document - EMILY NANKIVELL COLLECTION: BIOGRAPHICAL DETAILS, 1915
... . (d): Certificate of successful vaccination. Certificate.... (d): Certificate of successful vaccination. Certificate ...Documents. (a) Copy of Certificate of Marriage - Emily's parents: Edgar Nankivell and Emmaline Adelaide Osterfield, Married at Eaglehawk Methodist Church 1916. (b) Copy of Certificate of Marriage-Leslie Nicholas Grylls Thomas and Emily Isabel Nankivell 1949. (c); Copy of & 1 envelope from the Registrar of Births and Deaths, Stamp and postmark - Eaglehawk. Mr. E Nankivell Campbells Forest. (d): Certificate of successful vaccination. Certificate of Fitness notice to parents. Certificate of Unsusceptibilty Health Act 1915.document, names of bendigo pioneers, emily isabel thomas (nee) nankivell -
Eltham District Historical Society IncFolder, Peter Dousset, 1983
... breakdown truck towing a water trailer. 2. Copy of death certificate... breakdown truck towing a water trailer. 2. Copy of death certificate ...Contents: 1. Letter from Peter Dousset of Collaroy Plateau, NSW, Nov. 1983. Provides brief history of family origins in district. Grandfather was a French migrant who married an Australian woman in 1883 in Panton Hill and had four boys and two girls. Father worked for Ryan's Butcher shop in Panton Hill for many years. Parents retired to Hillside Avenue Eltham. Mother was kiiled by Burgoyne's truck in 1970 outside the Burgoyne shop (Inquest held Melbourne, 16 Dec 1970 VPRS 24/P0002, 1970/2408). Peter Dousset opened a garage in Research in 1948 with Kevin Brinkkotter and they started the Research Fire Brigade using his breakdown truck towing a water trailer. 2. Copy of death certificate, Ernest Pierre Dousset 13 May 1963 (VIC 9061/63), son of Pierre Francois Dousset and Christina Dousset (nee Newlands), buried Smiths Gully Cemetery (Queenstown Cemetery) 3. Copy of death certificate, Gladys Dousset (nee Stutley), 12 Oct 1970 (VIC 885/71), daughter of Alfred Stutley and Ester Stutley (nee Thomas) 4. Copy of six pages extracted from an autobiography written by Peter Dousset 5. Copy of photo taken 1912 outside the Panton Hill Hotel with Peter Dousset's grandparents on the right side 6. Copy of photo of the Dousset family home in Panton Hill 7. Copy of vaccination certificate of Pierre Dousset aged 6 months at Panton Hill, 26 October 1897 [Items 2-7 are digital file copies only] Folder of information on Peter Dousset and ancestors, Panton Hill and Researchpeter dousset, burgoyne's shop, eltham, kevin brinkkotter, panton hill, research (vic.), research fire brigade, ryan's butcher shop, panton hill hotel, hillside avenue, alfred stutley, christina dousset (nee newlands), ernest pierre dousset, ester stutley (nee thomas), gladys dousset (nee stutley), pierre francois dousset, queenstown cemetery, smith's gully cemetery -
Bendigo Historical Society Inc.Document - LEA FAMILY COLLECTION: DOCUMENT
... Certificate of Vaccination.... - 18/01/1866. c - Certificate of Vaccination for William John... and lining of a Coffin Certificate of Vaccination Mr Lea H Brailey ...A Malmsbury Cemetery Receipt for the Interment of a Child - 18/01/1866. b - Receipt for Trimming and lining of a Coffin. - 18/01/1866. c - Certificate of Vaccination for William John, Son of Charles Lea of Green Hill. - 2/11/1872.person, receipts, cemetery, lea family documents, malmsbury cemetery receipt for the interment of a child, receipt for trimming and lining of a coffin , certificate of vaccination, mr lea, h brailey, william henry lea, w lasslett, edward davy, william john lea, charles lea -
National Vietnam Veterans Museum (NVVM)Booklet, World Health Organization
... of said Organization and International Certificates of Vaccination... Organization and International Certificates of Vaccination wording ...Yellow Booklet issued by WHO and featuring the Symbol of said Organization and International Certificates of Vaccination wording in black print. All wording in both English and French. 3790361 TM Collie in blue pen. Issued to passport number or travel document no G 495622Nine pages detailing dates and Vaccinations plus information for soldier and Physicians in both English and French. Some stamped.booklet, who, medical -
Bendigo Historical Society Inc.Document - MERLE BUSH COLLECTION: CUTTINGS, RECEIPTS AND VARIOUS ITEMS
... for purchase of Ladies cycle 1909 and guarantee; 10. Certificate... and guarantee; 10. Certificate of Vaccination for Muriel Bush, daughter ...Collection of Merle Bush Ephemera - cuttings, letters etc relating to Bush family; 1. obituary Albert Bush , Bairnsdale Advertiser 6th June 1916; 2. Obit Albert Bush ''Every Week'' (Bairnsdale), June 8th, 1916; 3.Retirement of C R Stilwell, 1899; 4. Balance Sheet (single page handwritten) June 1st 1916; 5.Handwritten details of children born to Albert Bush - 1860 - 1878; 6. Receipt for purchase of ''Villa Abbey Lieux'' (1921) on letterhead of Stan Hall, Furniture New and Second-hand, Hargreaves St. (725 Pounds); 7.signature of A Bush (dated 1851?); 8.receipt for Federal Palace Hotel accommodation October 1902; 9. Receipt for purchase of Ladies cycle 1909 and guarantee; 10. Certificate of Vaccination for Muriel Bush, daughter of A Bush , 1897; 11.handwritten copy of letter regarding appointment of Executor to will (addressed to Albert Bush), September 1905.person, individual, bush collection - personal -
Southern Sherbrooke Historical Society Inc.
Information folder - Edelston family
... . -Medical certificate of vaccinations and innoculations, Edwen..., 1965, re. death of Dr Ronald Hyde. -Medical certificate ...Ephemera collected by Edelston family.Information folder containing items pertaining to the Edelston family. Contents: -Sheet of lined paper with hand-written names and dates of birth. -Southern Sherbrooke Historical Society data sheet, containing names and dates of birth. -Article, "Narre North lass weds leading footballer", re. Vivienne Loveridge and Geoffrey Beasley. -Article, "Doctor, 43, shot dead: Wife hit", Sun, 26th January, 1965, re. death of Dr Ronald Hyde. -Medical certificate of vaccinations and innoculations, Edwen Edelston, army record dated 1958. -Record of Services card, National Service, Edwen Edelston, dated 1958./Photo, party scene. -Baby Show certificate, Menzies Creek branch of the Red Cross Society, awarded to Leigh Edelston, plus photo of Leigh (?) and father. (2 copies) -Invitation to Robin Edelston's 21st birthday party, 24th January 1959, family photograph, and card notifying of change of venue for party. -Notice of change of venue for Robin Edelston's 21st birthday party, with small photos (apparently taken at the event) attached. -Article, "They helped Robin to celebrate". re. 21st birthday, with small photos attached. -Article, "Novel jet-age touch for spectacular Belle of Belles Ball", Dandenong Journal, 2nd November 1960 -Article, "Fourteen Belles for big Belle of Belles Ball this Friday night", also card "A. W. Edelston/builder and designer" -Royal Melbourne Hospital School of Nursing Contract of Service by student nurse, for Cherry Edelston, dated 11 December 1957, with photo of Cherry attached. -Poem, "Growing Old" by William Powell: cover of wedding service, St John's Church of England, Malvern, 10 December 1960 for Cherry and Brian; photo of de Rooy family house destroyed by fire, April 1962: article, "Surprise shower tea for bride-elect"/Photo, "Signing the register", marriage of Cherry Edelston & Brian Fischer, 12 December 1960; article, "It was a great night for Cherry"; card, Wild Cherry Cafe, 163 Collins St; photo, Brian & Cherry Fischer; epithet, "Of all my wife's relations I like myself the best". -Article, "Engagement announced at 21st birthday party", re. engagement of Cherry Edelston and Brian Fischer; thankyou card. -Article, "Married in same church as her parents", re. Cherry and Brian Fischer; bereavement card, Mrs Lillian Davie and daughter, dated August 1861; article, "'Miss City' sets the wedding date", re.Cherrie Gillingham. -Article, "Kerry Fox, many times belle, was pretty bride", re. Kerry and Edwen-Robin Edelston, Dandenong Journal, 1963, plus photo of bride and groom; card dated 4 January 1963, from Kerry & Robin to Mr & Mrs E. -Article, "Kerry Fox, hospital Ball belle at Narre Warren"; article, untitled from Weekly Times, on same subject, dated 12 December 1962. -Photo, Kerry Fox & Robin Edelston, re. Belle of Belles. -Photo, Kerry & Robin Edelston; engagement notice, Free Press, Fox-Edelston; article, "Double party: engagement, birthday, NWN"; Dandenong Journal flyer; (2 copies).edelston family -
Glen Eira Historical Society
Document - Bromfield, Margery
Original license and faculty to marry Norman Edward Bromfield and Margery Eva Reed, at St Catharine’s Church, Caulfield, dated 01/02/1924. Also original certificate of statutory declaration for non-vaccination of child of M Bromfield, dated 27/03/1925.bromfield norman edward, reed margery eva, schwieger c p, st catharine’s church, caulfield, marriage certificates, bromfield margery eva, bromfield harry norman, certificates -
City of Moorabbin Historical Society (Operating the Box Cottage Museum)Certificate - Document, Certificate of Burial 1890, c1880
James Jones was the son of Philip Jones, a Chairmaker, and Ann Jones who settled in East Brighton after the sale of land c1852 in the area of the Henry Dendy Special Survey of 1841. Mary Ann Moore was the daughter of Thomas Moore, a Gardener, and Sarah Harris who also settled in Brighton c1852. James and Mary Ann Jones settled and raised their family in East Brighton now Bentleigh. Mr John Herron resided at 4 Vickery St Bentleigh until 1989. Sadly Martha Jones born 1888 died in 1890 and James Jones had to purchase this plot at Brighton General Cemetery for her burial. A further 2 children were interred in 1893 and 1900 then Mary Ann in 1903 and James in 1940 James Jones and Mary Ann Moore were born in Brighton c1857 and c 1859 into pioneer market gardener families in the area of the Dendy Special Survey of 1841. They married in 1883 and raised their family in East Brighton, now Bentleigh. Sadly infectious diseases took the lives of many infants throughout the Colony of Victoria due to the poor state of water supply and sewerage disposal and locally the swamps of the Elster Creek were a constant breeding ground.An original paper Certificate of Right of Burial in The Brighton General Cemetery signed and dated by the Trustees of the Cemetery upon the application of James Jones of East Brighton, Victoria, 22nd April 1890. A plot , Register No. 2844, of 4 feet in width and 8 feet in depth in the Wesleyan Section, No. 199, compartment G in the Brighton General Cemetery. would be supplied upon payment of Two Pounds two shillings and receipt of same is acknowledged. Certificate of Right of Burial / IN THE / BRIGHTON GENERAL CEMETERY. Application of Mr James Jones of East Brighton for a plot to be supplied upon payment of Two Pounds and 2 Shillings and receipt of same acknowledged. Signed by the Trustees of the Cemetery, (4 signatures) in presence of S. Simmonds, dated twenty- second April 1890 Reverse side Dated 22nd April 1890 / Certificate of Right of Burial / IN THE / BRIGHTON GENERAL CEMETERY/ Mr James Jones ( hand written) / DENOMINATION Wesleyan / Compartment G / No. 199 Hand written on right side 3454 (signed) S Simmonds / 4797 (signed) S Simmonds / 36897 20/ 11 / 40 melbourne, brighton, moorabbin, water supply, pioneers, bentleigh, dendy henry, market gardeners, early settlers, jones mary ann, wesleyan church, jones james, vaccination, typhoid, dendys special survey 1841, infectious diseases, elster creek, jones martha, brighton general cemetery -
City of Moorabbin Historical Society (Operating the Box Cottage Museum)Document - Wedding Certificate, Elizabeth Jones, c1917
James Jones was the son of Philip Jones, a Chairmaker, and Ann Jones who settled in East Brighton after the sale of land c1852 in the area of the Henry Dendy Special Survey of 1841. Mary Ann Moore was the daughter of Thomas Moore, a Gardener, and Sarah Harris who also settled in Brighton c1852. James and Mary Ann Jones settled and raised their family in East Brighton now Bentleigh. They sadly lost Martha Jones born 1888 died in 1890 ,and. Baby Ethel May died 1893 and a stillborn baby was buried in 1900. However, their daughter Elizabeth Ann Jones born 1885 married John Patrick Kennedy born 1885, a the son of Thomas Kennedy , Dairyman deceased, and Jane Donovan early settlers in the Brighton area, at South Melbourne in January 1917 . James Jones and Mary Ann Moore were born in Brighton c1857 and c 1859 into pioneer market gardener families in the area of the Dendy Special Survey of 1841. They married in 1883 and raised their family in East Brighton, now Bentleigh. Sadly infectious diseases took the lives of many infants throughout the Colony of Victoria due to the poor state of water supply and sewerage disposal and locally the swamps of the Elster Creek were a constant breeding ground. Martha Jones born 1888 died 1890 and was interred in the Brighton General Cemetery. In 1893 another daughter Ethel May died and stillborn baby in May1900. Mary Ann Jones died, at age 43years, in January 1903 and in November 1940 Mr James Jones was buried in the family grave. Their daughter Elizabeth Ann Jones , born 1885, married John Patrick Kennedy, born 1885, the son of Thomas Kennedy, a dairyman and Jane Donovan also early settlers in Brighton area at St Luke’s Anglican Church in South Melbourne in January 1917 Original Certificate of Marriage of Elizabeth Ann Jones, the daughter of James and Mary Ann Jones, to John Patrick Kennedy at St Luke's Anglican Church in South Melbourne on January 1st 1917In the State of Victoria/ crest/ In the Commonwealth of Australia/FOURTH SCHEDULE ACTSNOS. 2691 and 2720 -FORM B/ CERTIFICATE OF MARRIAGE B/ Year 1917Parish or Church District South Melbourne Denomination Church of England/ signed by Patrick Kennedy and Elizabeth Jones, witnesses Ada Hewton and Alice Steedman and Vicar David Ross Hewton dated this first day of January 1917anglican church, st luke's south melbourne, jones elizabeth ann, kennedy john patrick, kennedy thomas, donovan jane, dairyman, dairy farms, brighton general cemetery, vaccination, pioneers, early settlers, typhoid, brighton, moorabbin, bentleigh, market gardeners, jones james, jones mary ann, jones martha, dendy henry, dendys special survey 1841, infectious diseases, water supply, elster creek, melbourne, jones ethel may, reverend hewton david ross -
Whitehorse Historical Society Inc.Document, Louisa Schwerkolt Vaccination, 1890
... Vaccination of Louisa Schwerkolt born 24 Sep 1890. 2... & Certificate of successful Vaccination. Vaccination of Louisa ...Vaccination of Louisa Schwerkolt born 24 Sep 1890. 2 documents including Notice to parents & Certificate of successful Vaccination.Vaccination of Louisa Schwerkolt born 24 Sep 1890. 2 documents including Notice to parents & Certificate of successful Vaccination.Vaccination of Louisa Schwerkolt born 24 Sep 1890. 2 documents including Notice to parents & Certificate of successful Vaccination.schwerkolt, louisa -
Kew Historical Society Inc
Archive (series) - Subject File, Medical practitioners, 1909-2012
... .) doctors -- kew (vic.) vaccination certificates Eric Toft David ...Kew Historical SocietySince its foundation in 1958, members of the Kew Historical Society have been compiling and storing information about subjects relating to the history of Kew and its environs, of which this file is an example. Arranged by Secondary Values (value of records to users)Subject file created by researchers of the Kew Historical Society containing primary and secondary sources relevant to the history of medical practice in Kew. The file contains a diverse range of documents about doctors who practised in Kew, a vaccination certificate, profiles of medical practitioners published in the media, and letters from doctors to patients. spanish influenza, medical practitioners -- kew (vic.), doctors -- kew (vic.), vaccination certificates, eric toft, david hill, michael carr-gregg, gregory whelan, prof david horgan, gustav nossal, j.g. mcmahonspanish influenza, medical practitioners -- kew (vic.), doctors -- kew (vic.), vaccination certificates, eric toft, david hill, michael carr-gregg, gregory whelan, prof david horgan, gustav nossal, j.g. mcmahon -
Clunes Museum
Administrative record - IMMUNISATION NOTICE, 1908
MR. LACHLAN McLENNAN OF GEORGE STREET CLUNES - GENTLEMAN TO ATTEND DOCTORS RESIDENCE FOR HIS CHILD WINIFRED MAUD MCLENNAN TO RECEIVE VACCINATION 21ST JULY 1908.DOCUMENT OF NOTICE FOR CHILD TO BE VACCINATED BY MEDICAL PRACTIONER OR PARENT WILL BE LIABLE TO A PENALTY OF TEN TO FORTY SHILLINGS.local history, certificate, health -
Glenelg Shire Council Cultural CollectionCertificate - Certificate - Statutory Declaration, 08/05/1929
Certificate of Statutory Declaration, certifying that H.L. Vivian believes vaccination would be prejudicial to the health of his daughter, Betty Wallis Vivian, born 12/2/1929. Printed form on pale blue paper, details in black ink.
