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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

66700516

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

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

Date of Birth October 17, 1919 Place of Birth Glace BayCounty of Cape Breton

Name of Father Charles Kublek MAIDEN NAME of Mother Ellen N. Kublek

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

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

Occupation of Father at Birth of child Miner Place of birth of Father Wallen, Russia

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

Signature of Applicant Charles Kublek Address of Applicant Caledonia Mines Date 23 October 1919

Relationship of Applicant to child father

AFFIDAVIT

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

Born at Glace Bay in the County of Cape Breton

That CharlesKublek Whose Birth is sought to be registered was

born at Glace Bay Cape Breton County on October 17, 1919

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

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