The undersigned royal government certifies hereby, that a permit of emigration has been granted to, (name, profession, residence,) at his request, and for his emigration to——with his wife, formerly Miss——, and the following minor children, still being under the authority of the father:
[Name and time of their birth.]
This permit of emigration causes the loss of the quality of Prussian subject from the date of its delivery, only, however, for those persons expressly named therein.
The day of——.
ROYAL PRUSSIAN GOVERNMENT.
[seal.]
(No.——.)