Appeared to me, R.P. Cleveringa, Maire.... etc. etc... Jan Jelles, living in Appingedam, who declared to accept as his Family name the name Pelmulder and as his First name or names, the name or names of Jan Jelles; that he has ------- Son and --------- Daughter ----------- Grandson --------- Granddaughter, named --------

And has the Appearer besides me undersigned this certificate the 5-th February 1812.

[*Signatures] Jan Jelles Pelmulder

R.P.Cleveringa

Transcriptions: Albert Geurink.
Date: October 3, 2004.

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