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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000941

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Charles WalterJollimore Sex Male

Date of Birth June 19, 1921 Place of Birth Cape JohnCounty of Pictou

Name of Father Frank Jollimore MAIDEN NAME of Mother Euphamie Jollimore

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

Residence of Father when child was born Cape John Present address of Father Deceased

Occupation of Father at Birth of child Fisherman Place of birth of Father River John

Race Name and present address of Physician in attendance at birth

Signature of Applicant Charles Jollimore Address of Applicant RR4 River John Date June 16, 1981

Relationship of Applicant to child self

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Charles WalterJollimore

Born at Cape John in the County of Pictou

That Charles WalterJollimore Whose Birth is sought to be registered was

born at Cape John Pictou County on June 19, 1921

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

Census and data of school record

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