| Transcript or Index | Transcript of the pre-printed form that overseers are requested to complete:
A true list of all Lunatics and dangerous Idiots within the [jurisdiction, e.g. Parish, of place name] in the County of Derby, specifying the name, sex, and age of each Lunatic and Idiot, and whether such Lunatics be dangerous or otherwise, and for what length of time such Lunatics have been disordered in their senses, and where confined, or how otherwise disposed of.
[Table with the following headings: Name, Age, Sex, Whether Lunatic or Idiot, Whether dangerous or otherwise, For what length of time disordered in his or her senses, Where confined and since what time, At what Expence]
Sworn by [name] Overseer of the Poor of the said [jurisdiction, e.g. Parish] of [place name] aforesaid, before me, one of his Majesty’s Justices of the Peace acting in and for the said County of Derby, at [place] this [date] day of [month] in the Year of our Lord Thousand Eight Hundred and Thirty [year]
[Signature of Justice of the Peace] |