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TO WIT:
"THE CANADA TEMPERANCE ACT, 1878."
1
?.TO. Polling Day 16th July, 1885.
Declaration of Inability to Read.
of being numbered
on thl voters' list for the Polli4g Subdivision No. ,.in
do hereby declare that I am -unaV 6 to read (or that I am from
Physical incapacity".iinable to mark a ballot paper, as the case way 6e).
-,.(I! is X Mark)
The Ifth day of, July, A. D.
Odra
•
Form o/ Atleslalio Clause to'be written upon or annexed to Ihe Declaration of
Inability to Read.
L the undersigned, being the Deptity Returning Officer for Foiling 6_ibdivisio1l Xo.
for
do hereby certify that the above (or as the case may be) declaration, having been -read f *the above named
was signed by him in my presence witty his nrk.
Deput,Returning Officer.
Dated this 16th day of July, A. D., 1885."-