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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000222

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

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

Date of Birth December 3, 1924 Place of Birth SydneyCounty of Cape Breton

Name of Father Joseph Peter Dziubek MAIDEN NAME of Mother Mary Rzepa

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

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

Occupation of Father at Birth of child Steel Worker Place of birth of Father Poland

Race Name and present address of Physician in attendance at birth

Signature of Applicant Walter Dziubek Address of Applicant 37 Ferris Street, Sydney, Cape Breton Co., NS Date 2 March 1960

Relationship of Applicant to child Self

AFFIDAVIT

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

Born at Sydney in the County of Cape Breton

That WalterDziubek Whose Birth is sought to be registered was

born at Sydney Cape Breton County on December 3, 1924

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

Information received from parents Information on Baptismal certificate

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