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I, Saml F. Potter —, a resident of New Hanover County, N. C., am personally acquainted with Betty Moore who, is destitute &, who reside's in 
[[strikethrough]] The Cou [[/strikethrough]] New Hanover County, N. C., and state, to the best of my knowledge and belief [[blank]], that [[blank]] unable to maintain [[blank]], and [[blank]] no friends to assist [[blank]], and [[blank]]  
worthy of charity from the government. 

S.F. Potter SEAL

Sworn and subscribed before me, [[blank]], this 8 day of Feby, 186 [[strikethrough]] 6 [[/strikethrough]] 7.

A. L. Waddell J.P.

NOTE. — This Certificate must be signed and sworn to before some Magistrate, Justice of the Peace, or Officer of the army.