CELLAR: Clean, filthy, mouldy, damp, very damp, wet, foul, dark.
KITCHEN: Large, small, clean, filthy.

LIVING ROOMS: Ample, small, light, dark, clean, filthy.
SOURCE OF WATER: Well, spring, cistern, run, hydrant.
CONDITION OF WATER: Good, bad, suspicious.
AMOUNT OF WATER: Abundant, sufficient, insufficient.
DRAINAGE Surface, sewer, good, bad.
PRIVY: Foul, overflowing, dangerous.
YARD: Clean, dirty, too shady, damp.
STABLE: Clean, filthy, offensive.

(State distance from well.)

SURROUNDINGS: Note any unsanitary conditions in neighboring lots, streets, alleys or houses.

PRESENT SICKNESS: Make diligent enquiry concerning all present and recent sickness in the house; also, of all deaths, and the causes. Note what most imperatively needs attention at the house, and under REMARKS record any matters which could not be entered under any other head on the blank.

-A sanitary survey made with care is of great value.

(0.) Badge.

GEO. G. GROFF, M. D.

STATE BOARD OF HEALTH

SANITARY CORPS.

(p,) Meal Ticket.

State Board of Health.

GOOD FOR ONE MEAL.

G. G. GROFF.

To....

(t.) Cellar Report.

JOHNSTOWN, PA.,

DEAR SIR: We have carefully examined the cellar of Mr.

residence on.

and find it in sanitary need of cleaning.

I hereby certify that.

has done.

as a

transportation to

Executive Officer.

street,

days' work at $.

per day

in the Sanitary Corps, from

to

Chief Deputy Inspector.