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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000619

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

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

Date of Birth May 16, 1921 Place of Birth New WaterfordCounty of Cape Breton

Name of Father Lawrence Stachowiak MAIDEN NAME of Mother Mary Glourczyk

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

Residence of Father when child was born New Waterford Present address of Father deceased

Occupation of Father at Birth of child Coal miner Place of birth of Father Poland

Race Name and present address of Physician in attendance at birth

Signature of Applicant Mrs. Mary Odo Address of Applicant New Waterford Date March 15, 1976

Relationship of Applicant to child Self

AFFIDAVIT

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

Born at New Waterford in the County of Cape Breton

That MaryStachowiak Whose Birth is sought to be registered was

born at New Waterford Cape Breton County on May 16, 1921

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

I have always used the date May 16, 1921 as my birth day. My Mother gave me his date and I used this date when I first entered school. Made my First Communion and eventually married. As proof I enclose herewith my marriage certificate and a zrox copy of my baptismal certificate

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