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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000517

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Eileen AgnesBlank Sex Female

Date of Birth March 28, 1920 Place of Birth DartmouthCounty of Halifax

Name of Father John Robert Blank MAIDEN NAME of Mother Caroline Sampson

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

Residence of Father when child was born Dartmouth Present address of Father deceased

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

Race German Name and present address of Physician in attendance at birth

Signature of Applicant Mrs. Eileen Mountain Address of Applicant Hatchet Lake Date July 30, 1970

Relationship of Applicant to child self

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Eileen AgnesBlank

Born at Dartmouth in the County of Halifax

That Eileen AgnesBlank Whose Birth is sought to be registered was

born at Dartmouth Halifax County on March 28, 1920

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

Baptism Certificate Marriage Record

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