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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000485

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Lola BelleCrouse Sex Female

Date of Birth March 21, 1924 Place of Birth WestfieldCounty of Queens

Name of Father Gilbert Crouse MAIDEN NAME of Mother Venita (Vernetta) Fralic (Frail)

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

Residence of Father when child was born Westfield, Queens Co., NS Present address of Father Westfield, Queens Co., NS

Occupation of Father at Birth of child Labourer Place of birth of Father Westfield

Race Name and present address of Physician in attendance at birth

Signature of Applicant G. Mansfield Address of Applicant RR #1, Caledonia, Queens Co., NS Date 29 December 1975

Relationship of Applicant to child Son

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Lola BelleCrouse

Born at Westfield in the County of Queens

That Lola BelleCrouse Whose Birth is sought to be registered was

born at Westfield Queens County on March 21, 1924

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

Baptismal & Marriage records

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