English Translation

MEDICAL CLEARANCE CERTIFICATE C DR I) CM 1-ITs=nb,11953 Temporary 1. 2 1 3 1. 2 37 ALD.K. identity D.D.T HEAT. OTHER (25) Dates of Disinfestation certificate Types issued-: (26) PhysIcAl COndtion on (27) ImMUNIZatION RECoRd ARRIVaL Number Date Bignature of Authority Type 080CI Date SVIOS L. M. a D. T 1. (Epid) 2. 3. Remarks D. 1. 2. T. 1. (Tab.) 2. 3. 0. 8. Date Initials Reaction Vacc. VAA Read. Arrival Medical (28) Final Medical Inspection-: Inspection : Date Data M. R. Medical Examiner Medieval Examiner (29) MOVEMENT AUTHORIZATION C () VOIA CO Rr 10-39781-1 U. S. GOVERNNENT PRLNTING OFFICE