Front:
L.H. 659-9-1936
TO THE DEPARTMENT OF HEALTH, STATE OF NEW JERSEY:
This is to certify that I have administered, as shown below, immunizing bio-
logicals furnished free by State, to:
(Name)
TOXOID, 2-dose type
TOXOID, 1-dose type
(Address)
*Important: For residence, name Township or Municipality in which child lives, not
the post office used.
Date
If no fee was charged, check here
Date
(Age, Sex, Color)
(Name and Address of Physician)
(Residence)
SMALLPOX VACCINE
Date
Was vaccination
successful .....
Back:
L. H.
STATE DEPARTMENT OF HEALTH
TRENTON, N. J.
USTA
DATE
ONE CEN
JEFFERSON
