PUBLIC HEALTH ACT, 1875. ---_----
... CLADI OF PROXY. To the Chairman of the Local Board for the District of This day of 189 I, the undersigned, having been appointed by of Owner [or Owners] of the property hereinafter described, which is situated in the parish of to vote as bis for their] proxy pursuant to the provisions of the Public Health Act, 1875, claim to have my name inserted in the Register of Owners and Proxies for the ...