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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000846

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Dorothy JaneVan Larken Sex Female

Date of Birth October 27, 1920 Place of Birth StellartonCounty of Pictou

Name of Father Frederick Charles Van Larken MAIDEN NAME of Mother Jemima Miller

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

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

Occupation of Father at Birth of child Miner/rope splicer Place of birth of Father Liege, Belgium

Race Name and present address of Physician in attendance at birth

Signature of Applicant Dorothy J. Van Larken Address of Applicant Stellarton Date August 2, 1977

Relationship of Applicant to child self

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Dorothy JaneVan Larken

Born at Stellarton in the County of Pictou

That Dorothy JaneVan Larken Whose Birth is sought to be registered was

born at Stellarton Pictou County on October 27, 1920

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

I am the mother of Dorothy Jane Van Larken

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