Hospital Form No. 121
Before the State Hospital Board
[underscore], Register No.[underscore]Inmate[long bracket]Order for Sexual Sterilization
Upon the petition of [underscore]
Superintendent of [underscore]
and upon consideration of the evidence introduced at the hearing of this matter, the Board finds that the said inmate is [long bracket followed by listing]
epileptic[second long bracket] and by the laws of heredity is the probable potential parent of socially inadequate offsprings likewise afflicted; that the said inmate may be sexually sterilized without detriment to [bracket]
her[bracket] general health, and that the welfare of the inmate and of society will be promoted by such sterilization. Therefore, it appearing that all proper parties have been duly served with proper notice of these proceedings, and have been heard or given an opportunity to be heard, it is ordered that[underscore]
have performed[end bracket]
by Dr. [underscore], on the said inmate the operation of [bracket]
after not less than thirty (30) days from the date hereof.
[underscore, flush right]
(Designated Member of Board)
Note: Make two copies; one for guardian or committee and one for Board.
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