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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000546

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Laura MaySample Sex Female

Date of Birth August 16, 1922 Place of Birth StellartonCounty of Pictou

Name of Father Alex Sample MAIDEN NAME of Mother Bertha Taylor

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

Residence of Father when child was born Stellarton, Pictou Present address of Father Deceased

Occupation of Father at Birth of child Miner Place of birth of Father Stellarton, Pictou

Race Name and present address of Physician in attendance at birth

Signature of Applicant Laura MacKenzie Address of Applicant 4 Doug Avenue, New Glasgow, Pictou Date 5 August 1975

Relationship of Applicant to child Self

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Laura MaySample

Born at Stellarton in the County of Pictou

That Laura MaySample Whose Birth is sought to be registered was

born at Stellarton Pictou County on August 16, 1922

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

Baptismal certificate and marriage extract.

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