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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000576

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of AgathaKupusa Sex Female

Date of Birth October 12, 1924 Place of Birth DonkinCounty of Cape Breton

Name of Father Fred Kupusa MAIDEN NAME of Mother Florence MacKenna

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

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

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

Race Name and present address of Physician in attendance at birth

Signature of Applicant Agatha Kupusa Address of Applicant 920Creamzie West, Unite 24, Montreal, Quebec Date 5 May 1978

Relationship of Applicant to child Self

AFFIDAVIT

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

Born at Donkin in the County of Cape Breton

That AgathaKupusa Whose Birth is sought to be registered was

born at Donkin Cape Breton County on October 12, 1924

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

My knowledge. I am Agatha Kupusa and my date of birth is 1924 October 12

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