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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

91600393

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Clyde ElsworthNickerson Sex Male

Date of Birth December 31, 1921 Place of Birth Cape Sable IslandCounty of Shelburne

Name of Father Cleveland Nickerson MAIDEN NAME of Mother Lottie Nickerson

Residence of Father when child was born Cape Sable Island, Shelburne Co., NS Present address of Father Kelleys Cove, Yarmouth Co., NS

Occupation of Father at Birth of child Fisherman Place of birth of Father Port La Tour, Shelburne Co., NS

Race Name and present address of Physician in attendance at birth

Signature of Applicant Mrs. Cleveland Nickerson Address of Applicant Kelleys Cove, Yarmouth Co., NS Date 20 June 1941

Relationship of Applicant to child Mother

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Clyde ElsworthNickerson

Born at Cape Sable Island in the County of Shelburne

That Clyde ElsworthNickerson Whose Birth is sought to be registered was

born at Cape Sable Island Shelburne County on December 31, 1921

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

I am Clyde Nickerson 's mother and well remember the date of his birth

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