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‘BE it remembered, That on the Day to wit. of A.B. is convicted before Her Majesty‘s Justices or Justice of the Peace for the County of by virtue of the Act passed in the Sixth Year of the Reign of Her Majesty Queen Victoria, intituled [here insert the Title of this Act, specify the Offence, and the Time and Place when and where the same was committed, as the Case shall be]; and we do adjudge that the said A.B. shall for the said Offence. Given under our Hands and Seals [or my Hand and Seal] the Day and Year aforesaid.’
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