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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000520

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Marie IsabelleDavid Sex Female

Date of Birth October 3, 1924 Place of Birth Petit de GratCounty of Richmond

Name of Father Willaard David MAIDEN NAME of Mother Marie Victoria (Torey) Samson

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

Residence of Father when child was born Present address of Father

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

Race Name and present address of Physician in attendance at birth

Signature of Applicant Mrs. Marie Victoria David Address of Applicant PO Box 28, Petit de Grat, Richmond Co., NS Date 27 October 1976

Relationship of Applicant to child Mother

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Marie IsabelleDavid

Born at Petit de Grat in the County of Richmond

That Marie IsabelleDavid Whose Birth is sought to be registered was

born at Petit de Grat Richmond County on October 3, 1924

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

Applicant is mother of Marie Isabelle David

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