‘City, Borough, or Place, to wit.
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}
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BE it remembered, that on the day of in the year of our Lord ,
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A.B. is convicted before me, C.D., one of his Majesty’s justices of the peace for the said city, borough, town, or place, by virtue of an Act made in the ninth year of the reign of King George the Fourth, intituled [here set forth the title of this Act], of having [here set forth the offence], and I do hereby adjudge that the said A.B. shall for the said offence forfeit the sum of Given under my hand and seal this day of in the year of our Lord .
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