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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000408

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of JaneBoch Sex Female

Date of Birth December 4, 1920 Place of Birth Glace BayCounty of Cape Breton

Name of Father   MAIDEN NAME of Mother  

Residence of Father when child was born Present address of Father

Occupation of Father at Birth of child Place of birth of Father

Race Name and present address of Physician in attendance at birth

Signature of Applicant Address of Applicant Date

Relationship of Applicant to child

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of JaneBoch

Born at Glace Bay in the County of Cape Breton

That JaneBoch Whose Birth is sought to be registered was

born at Glace Bay Cape Breton County on December 4, 1920

My knowledge of the fact and date of such Birth is based on the following Circumstances:

Died shortly after Birth.

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