I, A.B., the surgeon [or as the case may be] of the [describe prison]. hereby certify that I this day examined the body of C.D., on whom judgment of death was this day executed in the [describe same prison]; and that on that examination I found that the said C.D. was dead.

Dated this day of

(Signed) A.B.

We, the undersigned, hereby declare that judgment of death was this day executed on C.D. in the [describe prison] in our presence.

Dated this day of

(Signed) E.F., Sheriff of

L.M., Justice of the Peace for

G.H., Gaoler of

J.K., Chaplain of

&c. &c.