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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000999

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Manford BurtonNickerson Sex Male

Date of Birth June 10, 1921 Place of Birth Attwoods BrookCounty of Shelburne

Name of Father Burton James Nickerson MAIDEN NAME of Mother Henrietta Smith

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

Residence of Father when child was born Clarks Harbour Present address of Father deceased

Occupation of Father at Birth of child Labourer Place of birth of Father Clarks Harbour

Race Name and present address of Physician in attendance at birth

Signature of Applicant Manford B. Nickerson Address of Applicant 1632 Robert St. Plainfield, Indiana, USA Date December 4, 1982

Relationship of Applicant to child Same

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Manford BurtonNickerson

Born at Attwoods Brook in the County of Shelburne

That Manford BurtonNickerson Whose Birth is sought to be registered was

born at Attwoods Brook Shelburne County on June 10, 1921

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

School Records Passport Marriage Extract Fathers Pension Application

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