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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99100139

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of DorothyKokoszka Sex

Date of Birth February 18, 1922 Place of Birth SydneyCounty of Cape Breton

Name of Father Walenty Kokoszka MAIDEN NAME of Mother Rosalia Wojcik

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

Residence of Father when child was born Sydney, Cape Breton Present address of Father

Occupation of Father at Birth of child Place of birth of Father Poland

Race Name and present address of Physician in attendance at birth

Signature of Applicant Dorothy Kokoszka Address of Applicant 11155 Jacques Bizard Street, Montreal, Quebec, H3M 2W6 Date 12 July 1994

Relationship of Applicant to child Herself

AFFIDAVIT

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

Born at Sydney in the County of Cape Breton

That DorothyKokoszka Whose Birth is sought to be registered was

born at Sydney Cape Breton County on February 18, 1922

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

It was a known fact as established and celebrated by my parents and relatives that I was born on Saturday, February 18, 1922 as aforesaid. this fact was documented in my Baptismal certificate at the Parish of Nativity of Blessed Virgin (St. Mary's), February 26, 1922

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