Certificate of discharge.
| Name and official number of ship. | |
| Port of registry. | |
| Tonnage. | |
| Description of voyage or employment. | |
| Name of seaman. | |
| Place of birth. | |
| Date of birth. | |
| Character. | |
| Declines to give statement of character. | |
| Capacity. | |
| Date of entry. | |
| Date of discharge. | |
| Place of discharge |
I certify that the above particulars are correct, and that the above-named seaman was discharged accordingly.
Dated ———— day of ———— , eighteen hundred and ———— .
(Signed) ———— ———— , Master.
(Countersigned) ———— ———— , Seaman.
Given to the above-named seaman in my presence this ———— day of ———— , eighteen hundred and ———— .
(Signed) ———— ———— ,
Shipping-Commissioner.
(R. S., 4612.)