County of
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--------of----Couniy of--------

 On this--day of---in the year one thousand eigh, hundred aad--personally appeared before me the undersigned, a Jus lice of ;he Peace and--above mentioned,

 ---who, being duly sworn according to law, declares tha, he is the ideniicas-- ---who was--------in ihe company giment commanded by-------that he en- listed on lhe---Jay----of-----s--for the term ol----------snd WAS discharged at -----on the-------day of--------by reason of------

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