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English translation:

It happened in Kossuty on the third / fifteenth of January, eighteen hundred and forty six at eleven o’clock in the morning. The Jews Gimpel Jankielowicz Tandeta, age fifty six, and Herszko Leybowicz Donieli?, age forty seven, both of whom synagogue sextons residing in Zareby Koscielne, appeared and testified that today at five o’clock in the morning died the Jew Leybka Judkowicz Blumenfeld, tailor, age forty three, leaving behind his wife Cipa Szaiówna [bat Szaja] residing in Zareby Koscielne. After having convinced ourselves with our own eyes about the death of the Jew Leybka Judkowicz Blumenfeld, this document was read to those who appeared who are not related to the deceased, and signed by Us, the Holder of the Civil Records, whereas the witnesses declared that they cannot write.