No Record Certification of Birth
NO RECORD CERTIFICATION
STATE OF NEW YORK
DEPARTMENT OF HEALTH
THIS IS TO CERTIFY that a search has been
made for the birth record of
son
daughter of
(Name of father)
(Maiden name of mother)
which birth 1S said to have occurred on
(Date of birth)
at _........._.. _ _." _ n' _ _' _ ._... _ _ __ _. _.._ _ _ _ _ _...._ _......_ _... _ .__ _.._ _. _ _ _...... n
(Place of birth)
State of New York, and that such record is not on file in
this office.
(Registrar )
District No. _...____.......___n....
Dated at .n.n_____n_______.n.___nn.._nn____...._.n_nnn..n.' N. Y.
...n__........... un.....n... n..... n .__....n _.... n n.', _., 19.. nn
Form V.S.li (Rev. 1/63) (9A2.62)
