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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

66700104

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Wenzel RobertKubichek Sex Male

Date of Birth December 30, 1919 Place of Birth Sydney MinesCounty of Cape Breton

Name of Father Wenzel Kirbircher MAIDEN NAME of Mother Anna Blahout

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

Residence of Father when child was born Sydney Mines Present address of Father

Occupation of Father at Birth of child Miner Place of birth of Father Pilsen, Bohemia

Race Name and present address of Physician in attendance at birth Dr. Archibald

Signature of Applicant Wenzel Kirbircher Address of Applicant Sydney Mines Date 30 December 1919

Relationship of Applicant to child father

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Wenzel RobertKubichek

Born at Sydney Mines in the County of Cape Breton

That Wenzel RobertKubichek Whose Birth is sought to be registered was

born at Sydney Mines Cape Breton County on December 30, 1919

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

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