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PROVINCE OF NOVA SCOTIA

DELAYED REGISTRATION OF BIRTH

99000895

TO THE REGISTRAR GENERAL OF NOVA SCOTIA

I hereby make application for the Registration of Birth of Klissy ViolaDort Sex Female

Date of Birth May 2, 1924 Place of Birth Peas BrookCounty of Guysborough

Name of Father Levi Dort MAIDEN NAME of Mother Harriett Dort

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

Residence of Father when child was born Peas Brook Present address of Father deceased

Occupation of Father at Birth of child Labourer Place of birth of Father Peas Brook

Race Name and present address of Physician in attendance at birth

Signature of Applicant Marjorie Nickerson Address of Applicant Porters Lake Date March 30, 1988

Relationship of Applicant to child Daughter-in-law

AFFIDAVIT

IN THE MATTER of the application for the Registration of the Birth of Klissy ViolaDort

Born at Peas Brook in the County of Guysborough

That Klissy ViolaDort Whose Birth is sought to be registered was

born at Peas Brook Guysborough County on May 2, 1924

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

(1) Baptism (2) Marriage Extract (Place of Birth and Mother's maiden name)

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