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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

91400071

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Royal BruceBelliveau Sex Male

Date of Birth February 18, 1922 Place of Birth Wood HarbourCounty of Shelburne

Name of Father William Belliveau MAIDEN NAME of Mother Mary Alice Nickerson

Residence of Father when child was born Wood Harbour, Shelburne Co., NS Present address of Father Wood Harbour, Shelburne Co., NS

Occupation of Father at Birth of child Fisherman Place of birth of Father Middle East Pubnico, Yarmouth Co., NS

Race Name and present address of Physician in attendance at birth

Signature of Applicant Mary Alice Belliveau Address of Applicant Wood Harbour, Shelburne Co., NS Date 6 November 1941

Relationship of Applicant to child Mother

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Royal BruceBelliveau

Born at Wood Harbour in the County of Shelburne

That Royal BruceBelliveau Whose Birth is sought to be registered was

born at Wood Harbour Shelburne County on February 18, 1922

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

I am the mother of Royal Bruce Belliveau

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