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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000348

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Rex WarrenJacklyn Sex Male

Date of Birth February 26, 1921 Place of Birth ShelburneCounty of Shelburne

Name of Father Alfred Jacklyn MAIDEN NAME of Mother Gladys Saunders

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

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

Occupation of Father at Birth of child Truckman Place of birth of Father Shelburne

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

Signature of Applicant Rex Warren Jacklyn Address of Applicant 182 Grey St. Brantford, Ontario Date August 2, 1965

Relationship of Applicant to child Self

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Rex WarrenJacklyn

Born at Shelburne in the County of Shelburne

That Rex WarrenJacklyn Whose Birth is sought to be registered was

born at Shelburne Shelburne County on February 26, 1921

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

I am the said Rex Warren Jacklyn and I was informed by my parents that I was born on the 26th day of February 1921 and I have always believed my birthday on the 26th day of February and I was 44 years of age on the 26th day of February 1965

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