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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

92000864

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of StephenKozak Sex Male

Date of Birth February 16, 1922 Place of Birth SydneyCounty of Cape Breton

Name of Father Nikola Kozak MAIDEN NAME of Mother Catheryna Lukiw

Residence of Father when child was born Sydney, Cape Breton Co., NS Present address of Father Swan Plain, Saskatchewan

Occupation of Father at Birth of child Factory Labourer Place of birth of Father Ukraine

Race Name and present address of Physician in attendance at birth

Signature of Applicant Nikola Kozak Address of Applicant Swan Plain, Saskatchewan Date 23 March 1942

Relationship of Applicant to child Father

AFFIDAVIT

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

Born at Sydney in the County of Cape Breton

That StephenKozak Whose Birth is sought to be registered was

born at Sydney Cape Breton County on February 16, 1922

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

I as a father was present at the time

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