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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000081

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Douglas ClydeJackson Sex Male

Date of Birth January 18, 1922 Place of Birth YarmouthCounty of Yarmouth

Name of Father Samuel Jackson MAIDEN NAME of Mother Dorothy Barry

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

Residence of Father when child was born Yarmouth Present address of Father Deceased

Occupation of Father at Birth of child None Place of birth of Father Vancouver, British Columbia

Race Name and present address of Physician in attendance at birth

Signature of Applicant Mrs. Dorothy Fenton Address of Applicant Main Street, Yarmouth Date 21 January 1949

Relationship of Applicant to child Mother

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Douglas ClydeJackson

Born at Yarmouth in the County of Yarmouth

That Douglas ClydeJackson Whose Birth is sought to be registered was

born at Yarmouth Yarmouth County on January 18, 1922

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

That I am the mother of Douglas Clyde Jackson, born at Yarmouth, January 18th, 1922

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