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UNITED PROVINCES OF AGRA AND OUDH.                            33

VACCINATION FORM No. 6.

Weekly statement showing villages and towns in which new vaccinations were
                        performed during the last week.

                        Name of tahsíl—name of district—

Date of
vaccination.

Name of village
or mohalla with
town.

Distance and
direction from
tahsíl.

New operations.

Primary.

Revaccina-
tion.

Total.

Total ...

This statement should be submitted to the Assistant Superintendent of Vaccination
immediately after the expiry of the week and the Vaccinator should fill in all new vaccina-
tions in this list very carefully.

Date—                                                        Signature of Vaccinator —

                                                        5

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