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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

90600295

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Ethel LouiseSampson Sex Female

Date of Birth July 26, 1921 Place of Birth Bear RiverCounty of Digby

Name of Father Roy Robert Simpson MAIDEN NAME of Mother Bessie Rice

Residence of Father when child was born Bear River, Digby Co., NS Present address of Father Port Washington, New York, USA

Occupation of Father at Birth of child Farmer Place of birth of Father Bear River, Digby Co., NS

Race Name and present address of Physician in attendance at birth

Signature of Applicant Cornelius Simpson Address of Applicant Bear River, Digby Co., NS Date 14 June 1934

Relationship of Applicant to child Grandfather

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Ethel LouiseSampson

Born at Bear River in the County of Digby

That Ethel LouiseSampson Whose Birth is sought to be registered was

born at Bear River Digby County on July 26, 1921

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

That I am her grandfather and am aware of the date of her birth.

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