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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000564

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of PhilipSimon Sex Male

Date of Birth June 9, 1922 Place of Birth Glace BayCounty of Cape Breton

Name of Father Irael Simon MAIDEN NAME of Mother Dora Friedberg

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

Residence of Father when child was born Birch Grove, Cape Breton Present address of Father Deceased

Occupation of Father at Birth of child Merchant Place of birth of Father Lithuania

Race Name and present address of Physician in attendance at birth

Signature of Applicant Philip Simon Address of Applicant 58 Catherine Street, Glace Bay, Cape Breton Date 16 January 1976

Relationship of Applicant to child Self

AFFIDAVIT

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

Born at Glace Bay in the County of Cape Breton

That PhilipSimon Whose Birth is sought to be registered was

born at Glace Bay Cape Breton County on June 9, 1922

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

Copy of hospital record certified by competent official.

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