Section 2. On the day of 19 at [³] in the town village of [or the sub-division of in the district of ] [separat

2. On the day of 19 at [³] in the town village of [or the sub-division of in the district of ] [separately from any other practitioner] [⁴], I personally examined the said A. B. and came to the conclusion that the said A. B. is a lunatic and a proper person to be taken charge of and detained under care and treatment. 2. I desire to obtain an order for the reception of A. B. as a lunatic in the asylum of situate at [3]. 3. I last saw the said A. B. at on the [4] day of