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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000521

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Everett KeithScott Sex Male

Date of Birth September 12, 1923 Place of Birth West Green HarbourCounty of Shelburne

Name of Father Charles A. Scott MAIDEN NAME of Mother Barbara L. Stuart

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

Residence of Father when child was born West Green Harbour Shelburne Co. Ns Present address of Father deceased

Occupation of Father at Birth of child Fisherman Place of birth of Father West Green Harbour, Shelburne Co., NS

Race Name and present address of Physician in attendance at birth

Signature of Applicant Everett Keith Scott Address of Applicant West Green Harbour, Shelburne Co., NS Date June 5, 1975

Relationship of Applicant to child Self

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Everett KeithScott

Born at West Green Harbour in the County of Shelburne

That Everett KeithScott Whose Birth is sought to be registered was

born at West Green Harbour Shelburne County on September 12, 1923

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

Class "A" Baptismal Certificate

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