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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

65400256

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of John RobertSamuel Sex Male

Date of Birth February 5, 1924 Place of Birth New VictoriaCounty of Cape Breton

Name of Father Andrew Samuel MAIDEN NAME of Mother Emma Barry

Residence of Father when child was born New Victoria, Cape Breton Co., NS Present address of Father New Victoria, Cape Breton Co., NS

Occupation of Father at Birth of child Miner Place of birth of Father Edinburgh, Scotland

Race Name and present address of Physician in attendance at birth

Signature of Applicant Andrew Samuel Address of Applicant New Victoria, Cape Breton Co., NS Date 5 October 1927

Relationship of Applicant to child Father

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of John RobertSamuel

Born at New Victoria in the County of Cape Breton

That John RobertSamuel Whose Birth is sought to be registered was

born at New Victoria Cape Breton County on February 5, 1924

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

I am the father of the child

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