Schedule BI, the undersigned, hereby certify that

Schedule B

SCHEDULE B (See section 6) I, the undersigned, hereby certify that the child of , residing at has already had small-pox (or as the case may be) that I have (or a public vaccinator has) three times (or twice, as the case may be) unsuccessfully vaccinated , the child of , residing at , and I am of opinion that the said child is insusceptible of successful vaccination. Dated this day of 19 . (Signature of Medical Practitioner or Inspector.) (Endorsement by Superintendent of Vaccination.)