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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000474

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Donald BernardJack Sex Male

Date of Birth August 11, 1923 Place of Birth Bear RiverCounty of Annapolis

Name of Father Derby Ivan Jack MAIDEN NAME of Mother Esther Peck

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

Residence of Father when child was born Bear River Annapolis Co. Ns Present address of Father Deceased

Occupation of Father at Birth of child Contractor Place of birth of Father Bear River, Annapolis Co., NS

Race Name and present address of Physician in attendance at birth

Signature of Applicant Esther Jack Address of Applicant Date August 1973

Relationship of Applicant to child Mother

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Donald BernardJack

Born at Bear River in the County of Annapolis

That Donald BernardJack Whose Birth is sought to be registered was

born at Bear River Annapolis County on August 11, 1923

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

By records kept in the family bible.

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