FAMILY COURT FIRST CIRCUIT STATE OF HAWAI`I
In the Matter of Adoption of A [ ]MALE [ ]FEMALE CHILD, Born on: A [ ]MALE [ ]FEMALE CHILD, Born on: A [ ]MALE [ ]FEMALE CHILD, Born on: A [ ]MALE [ ]FEMALE CHILD, Born on: by [ ]the legal spouse of [ ]and [ ]the child(ren)'s legal parent [ ]husband and wife [ ]an unmarried person
MEDICAL CERTIFICATE FOR THE CHILD
CASE NUMBER FC-A NO.
Petitioner(s).
The undersigned, being duly licensed to practice medicine in the State of hereby acknowledge that he/she has examined that said child's physical and mental condition is as follows:
does , and finds
.
Date
Signature of Physician
Printed Name of Physician
Address: Telephone Number:
08/07/01 MEDICAL CERTIFICATE FOR THE CHILD