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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000331

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Lorne LaytonDernier Sex Male

Date of Birth July 2, 1924 Place of Birth Fort LawrenceCounty of Cumberland

Name of Father Lorne Frederick Dernier MAIDEN NAME of Mother Emma Lillian Chapman

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

Residence of Father when child was born Fort Lawrence, Cumberland Co., NS Present address of Father Deceased

Occupation of Father at Birth of child Farmer Place of birth of Father Fort Lawrence, Cumberland Co., NS

Race Name and present address of Physician in attendance at birth

Signature of Applicant Lorne Layton Dernier Address of Applicant Fort Lawrence, Cumberland Co., NS Date 15 March 1967

Relationship of Applicant to child Self

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Lorne LaytonDernier

Born at Fort Lawrence in the County of Cumberland

That Lorne LaytonDernier Whose Birth is sought to be registered was

born at Fort Lawrence Cumberland County on July 2, 1924

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

That I am a half brother of the applicant and fourteen years senior in age. His birthday has always been celebrated on July 2nd and it is common knowledge in the family he was born in 1924

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