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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000723

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

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

Date of Birth February 13, 1921 Place of Birth Sydney MinesCounty of Cape Breton

Name of Father John MacIntosh MAIDEN NAME of Mother Theresa Fortune

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

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

Occupation of Father at Birth of child Coal Miner Place of birth of Father Sydney Mines

Race Name and present address of Physician in attendance at birth

Signature of Applicant L. MacIntosh Address of Applicant 1570 Harmacy Ave. Scarborough, Ontario Date November 28, 1977

Relationship of Applicant to child Self

AFFIDAVIT

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

Born at Sydney Mines in the County of Cape Breton

That LewisMacIntosh Whose Birth is sought to be registered was

born at Sydney Mines Cape Breton County on February 13, 1921

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

Certificate of Baptism from Immaculate Conception Parish, Sydney Mines, Cape Breton Enclosing this certificate with application

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