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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000770

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Jessie StephenBlack Sex Female

Date of Birth June 3, 1920 Place of Birth Port WilliamsCounty of Kings

Name of Father James Black MAIDEN NAME of Mother Margaret Moir

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

Residence of Father when child was born Port Williams Present address of Father deceased

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

Race Name and present address of Physician in attendance at birth

Signature of Applicant Jessie S. Hefler Address of Applicant Halifax Date February 16, 1976

Relationship of Applicant to child self

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Jessie StephenBlack

Born at Port Williams in the County of Kings

That Jessie StephenBlack Whose Birth is sought to be registered was

born at Port Williams Kings County on June 3, 1920

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

School Registration, Lunenburg School Wedding Certificate

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