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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000744

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Andrew RaphaelKelly Sex Male

Date of Birth November 22, 1923 Place of Birth Glace BayCounty of Cape Breton

Name of Father Thomas Kelly MAIDEN NAME of Mother Margaret Carey

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

Residence of Father when child was born Present address of Father Deceased

Occupation of Father at Birth of child Barder - Miner Place of birth of Father Newfoundland

Race Name and present address of Physician in attendance at birth

Signature of Applicant Andrew Raphael Kelly Address of Applicant 104 Pelham Road, St. Catharines, Ontario Date 22 January 1979

Relationship of Applicant to child Self

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Andrew RaphaelKelly

Born at Glace Bay in the County of Cape Breton

That Andrew RaphaelKelly Whose Birth is sought to be registered was

born at Glace Bay Cape Breton County on November 22, 1923

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

The evidence contained in certificate of birth and baptism

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