Schedule., The Shipwrecked Passengers Ordinance

I hereby certify that, acting in conformity with the provisions of the Shipwrecked Passengers Ordinance, I have defrayed the expenses incurred in rescuing, maintaining, supplying with necessary bedding, provisions, and stores (a) and in forwarding to their destination .......................................... passengers [including .................................... cabin passengers (b)] who were proceeding from .................................... to .................................. ..in the ship .................................... which was wrecked at sea, etc. (c) And I further certify that the total amount of such expenses is ............................. . pounds, and that such expenses were duly incurred by me under the said Ordinance. Given under my hand this .................................... day of.................................... l9 ............ . ................................................... Governor. (a) If more passengers tvere rescued than forwarded, or if bedding, etc., was not supplied, alter the certificate to suit the facts of the case. (b) Omit words in brackets when necessary. (c) State generally the nature of the disaster and where it occurred. But if the passengers were only left behind without any default of their own, state the fact accordingly.