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Certificate of two Householders
Date
We certify that the abovenamed Applicant has been known to us for a period of _ years ; that to the best of our knowledge and belief the answers he has given to the foregoing questions are true ; and that he is a fit subject for admission to the Dunwich Benevolent Asylum.
Signatures _
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Certificate of Surgeon or Physician
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I certify that Henry Lentfar has been under treatment by me for a period of eighteen months; that he is suffering from paralysis; is physically unfit to work for a living; does not require constant medical attendance; and is a fit subject for admission to the Dunwich Benevolent Asylum
Signature Philip Phomton
Surgeon
Dunwich Hospital