TO THE RIGHT WORSHIPFUL THE PRESIDENT AND TREASURER, AND THE
WORSHIPFUL THE GOVERNORS OF BETHLEM HOSPITAL, LONDON.
_The humble petition of ----, on behalf of ----, of the parish of
----, in the county of ----, a lunatic, aged ---- years._
_SHEWETH_:
_That the said ----, having been disordered in ---- senses about ----
and no longer, and being in every respect a proper object of your
charity, as by the foregoing certificates will more fully appear_;
_Your petitioner prays that the said lunatic may be admitted into your
hospital for cure._
_And your petitioner will ever pray, &c._
[_Let the petitioner sign his name above._]
[*⁎* The petitioner must be as near a relation of the lunatic as
possible; but in default of such relative, then some friend of the
patient, or officer of the parish in which such patient resides.]
_I, the undersigned, a Governor of Bethlem Hospital, desire the above
lunatic may be admitted, if a proper object._
[*⁎* If the parties do not happen to know any governors, the signature of
a governor will be supplied at the hospital, when the petition is read.]