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N.B. —The applicant must insert in the blanfc spaces in the following paragraph the name of tho Society or Industrial Insurance Company from which a sum of money is sought to be obtained, and the sum sought to be obtained from such Society or Company, which cannot exceed £10. I apply for the certificate for the purpose of obtaining from the (a) Society or Company the sum of Dated this day of , 18 . (Signature.) Begttlations under which Applications for Certificates of Death for the purposes of "The Friendly Societies Act, 1877," must be made. The application must be made on a form similar to this, and must be signed by the applicant; and the fee of Is., if for one certificate only, must be paid at the time the application is made. If the application is for more than one certificate, the fee of Gd. must be paid for every certificate in excess of one. The application may be made on any day except Sunday, Good Friday, Christmas Day, or other duly-recognized public holiday. If the application is made otherwise than personally, it must, with tho fee of Is., be conveyed to the Eegistrar free of all cost to him ; and an envelope or cover of tho proper size must also bo sent, fully addressed, to the person to whom this document is to be returned. If it is to be returned by post, the necessary postage stamps must be affixed to such envelope or cover. Approved. Wm. E. E. Brown, Eegistrar- General. (a.) If the money is sought to be obtained from an Industrial Assurance Company, draw a Hue through the words " Society or." If it is sought to be obtained from a Friendly Society, draw a line through the words "or Company."

FORM No. 3. CERTIFICATE of the DEATH of a CHILD under Five Years of Age, issued for the purposes of "The Friendly Societies Act, 1877. Registration District of , in the Colony of New Zealand.

(a.) The cause of death of the ahove-mentioned child having heen entered in the register of deaths on the certificate of a Coroner after inquest held [or a registered medical practitioner who attended such deceased child during its last illness ; or a certificate under the hand of a registered medical practitioner; or satisfactory evidence—namely, (b) having, since the registration of tho death, been produced, that the probable cause of death of the above-mentioned child was (c) ] -. I grant this (d) certificate to be produced to the (c) , said to be liable for the payment of the sum of (f) £ on the death of the said child. Given under my hand this day of ,18 . (Signed) , Eegistrar. (a.) The Eegistrar will draw a lino through tho words or statements which do not apply to the case, (b.) State here the nature of the evidence produced, (c.) Insert here the probable cause of death as stated iv such certificate, or as ascertained by such evidence, (d.) State here whether this is the first, second, third, fourth, &c, similar certificate of thia death which has been issued, (c.) Insert here the name of the Society or Industrial Assurance Company. (/.) Insert here the sum for which the Society or Company is said to be liable, which cannot, together with the money mentioned in any previous certificate or certificates of the same death, exceed £6. Form No. 3. (To be printed on back of preceding Form.) Form of Application for a Certificate of tho Death of a Child under Five Years of Age, for tiie purposes of " Tho Friendly Societies Act, 1877." To the Eegistrar of Births and Deaths having the custody of the Eegister in which the death of the under-mentioned person is registered. I, the undersigned, hereby demand, for the purposes of the above-mentioned Act, a certificate of the

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