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New-York, [blank] This is to certify, that the bearer [blank] has, in my presence, subscribed to the declaration, agreeable to the terms of their Excellencies the Commissioners proclamation, dated at New-York, 30th November, 1776.
Printed form completed in manuscript. The proclamation referred to is Evans 14783: By Richard Viscount Howe of the kingdom of Ireland- and William Howe- Esq; ... the King's Commissioners for Restoring Peace to His Majesty's Colonies in North-America ... Given at New-York- this thirtieth day of November- 1776. The proclamation was printed by Macdonald and Cameron. Library copy completed in manuscript: "New-York [Suffolk County] ... the bearer [John Ketcham] ..."; signed at bottom: "Wm. Tryon."
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