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I John Southgate of the City of Norfolk in Virginia, do state and solemnly declare that I am not embraced within any of the exceptions of the Amnesty Proclamation of the President of the United States dated May 28th 1865 and that having taken the Oath prescribed thereby I am fully entitled to the benefits thereof as I am advised and believe.

Baltimore September 18th 1865

John Southgate.

Sworn to and subscribed before me a Justice of the Peace of the City of Baltimore this 18th day of September 1865.

Jos. W. Blake J.P