of
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---of--Couniy of------

 On this-day of--in the year one thousand eight hundred asd---personally appeared before me the undersigned, Jus itce of ;he Peace and-above mentioned,

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

 -on the--day of---by

 Sworn to and subscribed before me the day and year above written.