County of
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of--- On this-day of---in the year one thousand eight hundred asd--personally appeared before ne the undersigned, Jns- itce of the Peace and---above mentioned,

 ---who, being duly sworn according to law, declares that he is the identieal-- ---who was-------in the company commanded by Captain--------in the re- giment commanded by---that he en- listed on the----day--of------for inc term of-----and was discharged at

 ---on the-----day of---by Sworn to an.i subscribed before me the day and year above written