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a.—l 4

death of the person named in the subjoined schedule; such certificate" to bo written in the form on the back of this application.

Namo and Surname of the Deceased. Age. When Died. Where Died.

N.B.—The applicant must insert in the blank spaces in the following paragraph the name of the Society or Industrial Assurance Company from which a sum of money is sought to be obtained, and the sum sought to be obtained from such Society or Company, which caunot exceed £6. I apply for the certificate for the purpose of obtaining from the (a) Society or Company the sum of Dated this day of , 18 . (Signature.) Regulations under which Applications for Certificates of Death for the purposes of " The Friendly Societies Act, 1877," must be made. The application must be mado on a form similai* to this, and must bo signed by the applicant; and tho fee of Is., if for one certificate only, must be paid at the time the application is made. If tho application is for more than one certificate, the fee of Gd. must be paid for every certificate in excess of one. The application may be made on any day except Sunday, Good Friday, Christmas Day, or other duly-recognized public holiday. If the application is made otherwise than personally, it must, with the fee of Is., be conveyed to the Eegistrar free of all cost to him; and an envelope or cover of the proper size must also be sent, fully addressed to the person to whom this docu;r.ent is to be returned. If it is to be returned by post, the necessary postage stamps must be affixed to such envelope or cover. Approved. Wm. E. E. Beown, Eegistrar- General. (a.) If the money is so-tight to be obtained from an Industrial Assurance Company, draw a line through the words " Society or." If it is sought to be obtained from a Friendly Society, draw a lino through the words "or Company."

FORM No. 4. CERTIFICATE of BIRTH, issued for the purposes of "The Friendly Societies Act, 1877." Registration District of , in the Colony of New Zealand.

Form No. 4. (To be printed on back of preceding Form.) Foem of Application fct* a Ceetificate of Bieth, for the purposes of '-' The Friendly Societies Act, 1877." To the Eegistrar of Births and Deaths having the custody of the Eegister in which tho birth of the under-mentioned person is registered. I, the undeesigned, hereby demand, for the purposes of the above-mentioned Act, a certificate of the birth of the person named in the subjoijjed Schedule, such certificate to be written in the form on tho back of this application.

Child. 'ABENTS. Infoemant. Registbae. Child. a t. o P o E s _ a _■ B 6 - ° tT **•* j§ o O -g t*H _ ft I & _ 6 ■ ll a _ |ti m g ° _ » _ j_ __ a *> _ Fatheb. -2 E ■ £ -a a s M.0THEB. a S -a ■8 _ § 1 -i a B .J= s a «-e c. a «>.a i. f — CO * 8_§ ° _ be I al s O ha O 9 O d g S £"£ t. fl _p .h o ■« Ai : rt « h tj fl a __: «•» o & 'fl d fl fl t_ to ro w _ fl rH N CO .< | a "£ oh 2 6 'ec 0 P s g ~ 1. B e3 . 9 1_ ■SB (_ tn |1 o- .2 "■ 60 c_ 6 _ o fH oi CO _f I. N Given uider my hand this ■y of ,18 (Si| ;ned .Eej itrar.