personally appeared _______________________________________________________
___________________________________________________________________________
___________________________________________________________________________
to me personally known to be the same person_____described in and who
executed the within declaration of occupation, and acknowledged that ______
h_____ signed, sealed and published the same as ______h_____ free and
voluntary act and deed for the uses and purposes therein set forth.
WITNESS my hand and seal, this _____________ day of _____________________,
19____
My commission expires _____________________________________________, 19____