Note 615 — Chapter X · ABOLITION AND DISEASE
Reading edition
I herewith acknowledge, that Dr. —— has called my attention to the following points:
1. That I am suffering from Syphilis.
2. That my disease is contagious for at least .. years.
3. That I am punishable, if I in any way expose others to infection.
Copies of Penal Code, Sections 155 and 358 received.
Date.
Signature.