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. r <br /> r�{1 <br /> J,I <br /> p Form R-5 <br /> ,a.couNTY Obt Tommunwea th of Massarhusttt <br /> FULL NAME OF FATHER PRINT 2A.CITYnOWNMAI<INGRETURN <br /> ¢ BARNSTABLE DEPARTMENT OF PUBLIC HEALTH MASHPEE <br /> LEGIBLY OR m 16.CITY/TOWN REGISTRY OF VITAL RECORDS AND STATISTICS <br /> 1 TYPE WITH H O 28/.REGISTEARED NUMBER <br /> w MASHPEE DELAYED RETURN OF BIRTH b� TS <br /> PERMANENT { Q 7C.FACILITY-NAME-IF NOT IN FACILITY,NUMBER AND STREET 2C.DEPOSITION NUMBER , <br /> BLACK INK. IL 1 <br /> THIS IS A L NAME: 3A.FIRST 3B.MIDDLE 3C.LAST <br /> - ----- PERMANENT DARIUS M, <br /> RECORD. p 4A.SEX MALE (Spec PLURALITYA. gle,Twin,etc.) (Specify Order TH ER(Second single, 6A.TIME 6B.DATE OF BIRTH(Month,Day Year) <br /> 4B COLOR <br /> M NAME: 7A.FIRST 78.MIDDLE 7C.LAST 7D.MAIDEN/BIRTH SU AME <br /> - -- - G q, <br /> � T BIRTHPLACE: 8A.CITY MN 8B.STATE/COUNTRY 9.00CUPATION 10.AGE-IDJATERE OF BIRTH 1949X <br /> H MEDCATOR <br /> �. <br /> 1 { E RE11A.NUMBERNDSTREET 11 B.CITY/TOWN 11 C.COUNTY 11D.STATE 11 E.ZIP CODE 12.COLOR/RACE <br /> )al I 19 SIDENCE:R (Do not use <br /> mailing address) 94 MA _FINDIAN <br /> F NAME: 13A.FIRST 'TR 136.MIDDLE 13C.LAST 14.COLOR/RACE <br /> T MELVIN SHERMAN COOMBS INDIAN ; <br /> E BIRTHPLACE: 15A.CITY/TOWN 15B.STATE/COUNTRY' 16.OCCUPATION 17.AGE/DATE OF BIRTH <br /> R MASHPEE MASSACHUSETTS GAS COMPAN JANUARY 30 1948 <br /> -- C 18A-TAY iPE 18B.TITLEOTHE <br /> r <br /> R74J AT-BIRTH ❑POST-NATAL ❑ THECERTIFIER ONLY ElSPECR ❑MD/DO ❑CNM ❑OTH.RN ®MIDWIFE ❑SPECR r :' <br /> T 19.NAME l;gra i <br /> 19A.LICENSE NUMBER <br /> F MADELINE FOODEN N/A r^ "' <br /> i 20A.NO.&STREET 20B.CITYITOWN 20C.STATE 20D.ZIP COPJE <br /> R 157 CENTER STREET PLYMPTON MASSACHUSETTS 02367 ;, : <br /> 21A.NAME OF DEPONENT(S) 21 B.ADDRESS- 21C.RELATIONSHIP TO CHILDLINDA JEFFERS COOMBS MOTHER <br /> C <br /> L 22. <br /> i all•;!„'sir <br /> The above record with reference to the evidence and deposition(s)on the reverse of this form has been entered upon the - 1•a <br /> birth records of the Ci /Town of MASHPEE in accordance with the provisions of General Laws, <br />_ ty P <br /> R JULY 1 1 9 91 <br /> Ch.46,Sec. on and attested copy of this form sent to the Commissioner of Public Health i r+ <br /> Mgnth,Day Near) <br /> K on 1 <br /> (Month,Day,Year)IR <br /> Q t � <br /> Clerk or Registrar �. <br /> c. <br /> y <br /> ; <br /> r,l - <br /> 1� <br /> ii rrl�. <br /> r}` <br /> 1' <br /> I- f <br /> I <br /> 'MELV'IN C# S - <br /> I F,; <br /> 1L <br /> Y� <br /> N <br /> u <br /> II X <br /> J1 <br /> 4 <br /> \.<i. <br /> a <br /> �� III1If <br />