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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000924

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Mary LorraineSamson Sex Female

Date of Birth December 9, 1922 Place of Birth Petit de GratCounty of Richmond

Name of Father Frederic I. Samson MAIDEN NAME of Mother Josephine Boudreau

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

Residence of Father when child was born Little Anse, Richmond Present address of Father Deceased

Occupation of Father at Birth of child Fisherman Place of birth of Father Petit de Grat, Richmond

Race Name and present address of Physician in attendance at birth

Signature of Applicant Mary L. Forster Address of Applicant 41 Cowie Hill Road, Halifax Date 7 February 1983

Relationship of Applicant to child Self

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Mary LorraineSamson

Born at Petit de Grat in the County of Richmond

That Mary LorraineSamson Whose Birth is sought to be registered was

born at Petit de Grat Richmond County on December 9, 1922

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

Baptism

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