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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000510

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

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

Date of Birth January 6, 1920 Place of Birth StellartonCounty of Pictou

Name of Father Arthur Leslie Samson MAIDEN NAME of Mother Daisy Jane Sample

Were the Parents married at the time of the Birth? Yes

Residence of Father when child was born Scotch Hill Present address of Father Toronto

Occupation of Father at Birth of child Farmer Place of birth of Father London, England

Race English Name and present address of Physician in attendance at birth Dr. Benvie, deceased

Signature of Applicant Hazel (Samson) Pearce Address of Applicant Westville Date August 28, 1969

Relationship of Applicant to child self

AFFIDAVIT

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

Born at Stellarton in the County of Pictou

That HazelSamson Whose Birth is sought to be registered was

born at Stellarton Pictou County on January 6, 1920

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

Bring the eldest daughter in this family, I was left in charge of the home and 4 younger children and as I was very young at that time shall never forget the date of that occasion.

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