Middlesex
to wit}

These are to Certify that this day Sarah Lakelan< no role >
came before me and made Oath that John
Chalk< no role > was taken ill of a fever the fifth day
of August last and died the thirteenth day of the
same Month and was Buried in Shadwell
Church Yard

Sworn before me
at the Public office Shadwell
22nd. October 1773}

Jno Sherwood< no role >

her
Sarah [mark] Lakelan< no role >
Mark