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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99100058

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

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

Date of Birth August 6, 1921 Place of Birth SydneyCounty of Cape Breton

Name of Father Martin Chmiel MAIDEN NAME of Mother Josephine Grefel

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

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

Occupation of Father at Birth of child Steelworker Place of birth of Father Poland

Race Name and present address of Physician in attendance at birth

Signature of Applicant Mary Chalipa Address of Applicant 113 Ferris St. Sydney Date June 15, 1984

Relationship of Applicant to child Self

AFFIDAVIT

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

Born at Sydney in the County of Cape Breton

That MaryChmiel Whose Birth is sought to be registered was

born at Sydney Cape Breton County on August 6, 1921

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

This is my own birth.

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