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State of Virginia,
[blank] OF [blank] TO WIT:
I [blank] for the [blank]
aforesaid, in the State of Virginia, do certify, that [blank]
[blank] whose name [blank] signed to the writing hereto annexed, bearing
date on the [blank] day of [blank] 185[blank], ha[blank] acknowledged the same before me in my
[blank] aforesaid. Given under my hand, this [blank] day of [blank] 185[blank].

State of Virginia,
[blank] OF [blank] TO WIT:
[blank] for the [blank] of [blank] in the State of Virginia,
do certify, that [blank] the wife of [blank]
whose names are signed to the writing hereto annexed, bearing date on the [blank] day of [blank]
185[blank], personally appeared before [blank] in the [blank] aforesaid, and being examined by [blank]
privily and apart from her husband, and having the writing aforesaid fully explained to her, she, the said
[blank] acknowledged the said writing to be her act, and declared
that she had willingly executed the same, and does not wish to retract it. Given under [blank] hand[blank], this
[blank] day of [blank], 185[blank].

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