Translated from Polish:

Death Record No. 10, Rychnów Parish, Kalisz, of Tekla Kowalczyk, born Chałka, who died in Rychnów on 24th May 1856, at 2 am, death reported on 26th May 1856, at 9 am. She was 50 years old. She was wife of Andrzej Kowalczyk, who served in Rychnów manor and she lived with him in Rychnów. She was born in Rychnów, daughter of Ignacy and Katarzyna, maiden name unknown, married couple Chałek, already deceased. After confirming with my own eyes the death of Tekla Kowalczyk, this record was read to those reporting the death and was signed by us. Death reported by Kazimierz Janas, 73 years old, and Stanisław Kraikiewicz, 33 years old, both farmers in Rychnów.