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    This document certifies that Jane Mary Doe, born March 22, 1960, an American citizen, received a yellow fever vaccination on June 5, 2018 in accordance with the International Health Regulations. The vaccination was administered by Dr. John M. Smith from a specific vaccine batch and is valid from June 25, 2018 until the end of the vaccinated person's life.

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    This document certifies that Jane Mary Doe, born March 22, 1960, an American citizen, received a yellow fever vaccination on June 5, 2018 in accordance with the International Health Regulations. The vaccination was administered by Dr. John M. Smith from a specific vaccine batch and is valid from June 25, 2018 until the end of the vaccinated person's life.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    5 views2 pages

    Figure - 4-02.png 1,200×868 Pixels

    Uploaded by

    Брат Брат
    This document certifies that Jane Mary Doe, born March 22, 1960, an American citizen, received a yellow fever vaccination on June 5, 2018 in accordance with the International Health Regulations. The vaccination was administered by Dr. John M. Smith from a specific vaccine batch and is valid from June 25, 2018 until the end of the vaccinated person's life.

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    © All Rights Reserved
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    of 2

    INTERNATIONALCERTIFICATEOFVACCINATIONORPROPHYLAXIS

    Certificatinternationaldevaccinationoudeprophylaxie

    Thisistocertifythat
    Nouscertifionsque
    (name-nom)
    JaneMaryDoe 22March.1960
    (dateofbirth-nélc)le)
    F
    (sex-desexc)
    UnitedStates
    (nationality-etdenationalité)

    (3)
    [passportnumber] whosesignaturefollows
    dontlasignaturesuit
    JaneMaryDoe
    [nationalidentificationdocument,ifapplicable-documentd'identificationnationae,lecaséchéant)

    hasonthedateindicatedbeenvaccinatedorreceivedprophylaxisagainst
    aétévacciné(elouareçuuneprophylaxieàladateindiquée
    YellowFever inaccordancewiththeInternationalHealthRegulations.
    (nameofdiseaseorcondition-nomdelamaladieoudel'affection) conformémentauRèglementsanitaireinternational.

    Vaccineorprophylaxis Date Signatureandprofessional Manufacturerandbatchno. Certificatevalid Officialstampoftheadministeringcenter


    statusofsupervising ofvaccineorprophylaxis from:
    Vaccinouagent Cachetofficielducentrehabilité
    clinician until:
    prophylactique Fabricantduvaccinoude
    Signatureettitredu l'agentprophylactiqueet Certificatvalable
    professioneldesanté numérodulot àpartirdu:
    responsable jusquau:

    (4) 5) (6) (7)


    Yellow [5 JohnM. Batch 25June
    2018;
    Fever June Smith,MD (orlot) lifeof
    2018 # person
    vaccinated
    :
    :

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