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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000256

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of AgnesMroz Sex Female

Date of Birth December 8, 1921 Place of Birth WoodsideCounty of Halifax

Name of Father John Mroz MAIDEN NAME of Mother Mary Piskorz

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

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

Occupation of Father at Birth of child Labourer Place of birth of Father Galicia, Poland

Race Polish Name and present address of Physician in attendance at birth

Signature of Applicant Mary Mroz Address of Applicant 250 Robert St. Sydney Date April 28, 1958

Relationship of Applicant to child Elder Sister

AFFIDAVIT

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

Born at Woodside in the County of Halifax

That AgnesMroz Whose Birth is sought to be registered was

born at Woodside Halifax County on December 8, 1921

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

Baptismal Certificate of St. Marys Church given under the hand of Rev. M.L. O'Connell and bearing the seal of the said Church dated 26 April AD 1958 hereto annexed and marked "A" by the Commissioner swearing me to this my declaration

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