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PREGNANCY CERTIFICATE

I certify that I have examined (1)
on (2)
and have found her physically able to travel by Air from
to (4)
and that the estimated date of birth of the baby is
Date (7)

(3)

on (5)
(6)

Signed (8)

Physician

1. Passenger's name
2. Date of Examination
3. Originating Point
4. Destined Point
5. Date of travel
6. Date of birth estimated
7. Date certificate issued
8. Signature of Physician

FORM PS-05-29A (901-1361)
(Rev. 4/71)
Original : Local file
Duplicate : Captain of flight
Triplicate : Passenger

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