Y .

~-o4a«x~l~Pn
~N~~~f,
l.,J/ Vacdnatian or Prophylaxis
World Health
Organization International Health Regulations (2005)

~
If;-~
I · I
~~
,;I
Certificat international de
vaccination ou de prophylaxie
Organisation
, mondiale de la Sante Reglement sanitaire international (2005)

f_nt,er~ational Vaccination Centr~

King lnst,tuta of Prevenu,,~ MP.rJicine & Res~a, ch
C~lndy, Chennai-600 032, :amilnadu, lildia
(AurhoNsed Ote GHS, MOHfW YELLOW FEVER VACCINATIONWffKEJ

Issued to/ Delivre a

· · ~ J·i ·~ t~~·~--· · · · · · · · · · ·
Passport number or
travel document number
,~·Nvrnero
:, .,~, .,.
du passeport OU
cu document de voyage
······· . . . 7-6tj2..4->6.3
....................................................................................................-............................. .
 5
4

INTERNATIONAL CERTIFICATE* OF VACCINATION CERTIFICAT* INTERNATIONAL DE VACCINATION

OR PROP HYLAXIS OU DE PROPHYLAXIE

This is to ceij that [name] .P..Y..6-\.f!..~ ..H..~!Y.J?..H I Nous certif ions que [nom ] ...................................................... .

.J.~.?.~..! s~x ............1Y.J..f.t.L.e.... ~

date of birthf?......?..~ ne(e) le ......... .................. . de sexe ............................................ .

b.J::.r...7?.. L .fr.r.i.............................
nationality .................... 1
t et de natio nalite ..................................... .................... ................ .
.SPO
.ASm•-1~
applicabieP1,~~• R'f .) 11
document d'identification national, le cas echeant ..........................
national identification document, if
L- a~~ ~ ~·;· dont la signa ture suit ................................................................ .
whose signature follows ······• ·~·:··r··:'·o -~ •r . · ~ J- I
has on the date indicated been vaccinated or received / a ete vaccine(e) ou a rec;: ug~e nts prophylactiques a la
pr~phyla.xis against (name ofdisease or condition) date indiq uee contre: (no~ e~m alad ie ou de !'affection)
I
u~
...........................................··~ ··8··· ...........................................
·········Y El·l·OW·FEVER······················································· ~ itaire intern ation al.
in accordance with the Intern ation al Healt h Regulations. j confo rmem ent au Reglem?ni:
2:'-A ..
00

Signat ure and Manu factur er and CertifilJittzalld Official stamp of

Vaccine or prophylaxis Date
Vaccin ou agent Date
profes sional status of I batch no. of vaccin e or l?e~ the administering
superv ising clinician proph ylaxis ~t~ centre
prophy lactiqu e
Signat ure et titre du Fabricant du Certifibrt & ble a Cachet officiel du
vaccin ou de !'agent p~ r:fi : centre habilite
~
Q
C"J
clinici en respon sable
prophylactique et
numer o du lot
j~u!i:
BIOMANGUJNH- LU .~

BRAZIL :c ;;:
~-+-----;~
~r--------+-~•~•~· 0C
v ~ ----r~ -----f-,----~ -=-:::: :.---ff; l:;+ll~ .___--- -+c:..- ¼l
~ .,.
t-
U.: _ No·
LOI •
-
·---
0 Z ,
o::c
....... -
~
c.o ~ (!)

irl
>- ....- D PUTY DIRECTOR
•
?
2
% \J "2- lc,3 z_ ~ ~

l * Requirements for validity of certificate on page 2. * Voir les conditions de validite ala page 3.