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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000683

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of StephenUlrich Sex Male

Date of Birth November 25, 1920 Place of Birth GardinerCounty of Cape Breton

Name of Father Louis Ulrich MAIDEN NAME of Mother Mary Mrazek

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

Residence of Father when child was born Gardiner Mines Present address of Father deceased

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

Race Czechoslovakian Name and present address of Physician in attendance at birth Dr. Densmore, deceased

Signature of Applicant Stephen Ulrich Address of Applicant Scotchtown Date June 1, 1974

Relationship of Applicant to child self

AFFIDAVIT

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

Born at Gardiner in the County of Cape Breton

That StephenUlrich Whose Birth is sought to be registered was

born at Gardiner Cape Breton County on November 25, 1920

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

Baptismal Certificate from Immaculate Conception Church, Bridgeport, Cape Breton

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