A Verified Transcript from the Register of Births
A Verified Transcript from the Register of Births
Name
of
Child
1 Family Name .....................................
J
..........................................
Given Name .......................................
..........................................
Sex (M. Male) (F. Female) ..........................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Place of Birth ..................................................
.............................................
Date of Birth ..................................................................................................
Color or Race if other than White .................................................................
Registered Number ........................................................................................
Number of this Mother's previous children ....................................................
How many of them now living ........................................................................
Name } Maiden ........................................................................................
of
Mother Married. . .. . . . . .... . . . . . .. . ... . . .... . . . . . . . . . . . . . .. . . . ..... ... . .... . . .. .. .. . .. .... . . ... . .....
Mother's Age ..................................................................................................
Mother's Birthplace ...... ...... ... .......... ........ ... .......... ...... ........ .,. .... .......... ....... ....
Name of Father................................................. ......... .............. ......................
Residence . . .. .., .,. .. ...... .., ..... .. .. . . .. . . .... .. ... .. ... ..... .... .,. .. .... . . ..... ., .... . . . .. . . ... .. . . . .... ..
Father's Occupation ...... ............................... ................................. ..... ...........
Father's Age ..................................................................................................
Father's Birthplace ........ ... ......;.. ................ ..... ..... ..... ..... .... .... ........ ... ..... .... ....
Medical Attendant, or other Attestant ........ ..................................... .... ...........
When Registered ............................................................................................
1 Hereby Solemnly Attest, That this is a true Transcript from the Public
Register of Births, as kept in the ..... ........... ............................................. ......
....................................................................................................
County of ........................................................................, State of New York
Dated at ....... ........ ...................... ..... ... ...... ..... ...... ............................ ...., N. Y.
the ................................ day of ................................................, 19........
(Signed) .................................................................................. ,...
Official Title.. .............. ........ ........ ......... ..... ....... ........... .... ......