This is to certify that ________________________ and _________________________________ has (have) been (a) member(s) of the _________________ Protestant Reformed Church ____________________________ until the date specified below.
Upon ______________ request this certificate was given him (them).
Done in consistory __________________________
___________________, President
_______________________, Clerk
(Cf. Acts of Synod, 1945, Arts. 40, 51; Acts of Synod, 1946, Arts. 17, 19.)