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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99100073

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of John AlbertSampson Sex Male

Date of Birth June 24, 1922 Place of Birth Little PondCounty of Cape Breton

Name of Father James Sampson MAIDEN NAME of Mother Rose Landry

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

Residence of Father when child was born Little Pond, Cape Breton Present address of Father Deceased

Occupation of Father at Birth of child Miner Place of birth of Father St. Pierre & Miquelon

Race Name and present address of Physician in attendance at birth

Signature of Applicant John A. Sampson Address of Applicant 22 First Avenue, Florence, Cape Breton Date 5 January 1987

Relationship of Applicant to child Self

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of John AlbertSampson

Born at Little Pond in the County of Cape Breton

That John AlbertSampson Whose Birth is sought to be registered was

born at Little Pond Cape Breton County on June 24, 1922

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

Certificate of Baptism

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