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a <br /> Form R-54. IOM-10-58-953918 <br /> h.e Cammna alf4 jof gasoadjuutts 254607 <br /> SECRETARY OF THE COMMONWEALTH <br /> DIVISION OF VITAL STATISTICS <br /> COPY OF RECORD OF BIRTH <br /> I, the undersigned, hereby certify that I am the Secretary of the Commonwealth of Massachusetts; <br /> that as such I have custody of the records of birth required by law to be kept in my office; that among <br /> such records is one relating to the birth of <br /> and that the following is a true copy of so much of said record as relates to said birth, namely:--- <br /> Name <br /> Date of Birth <br /> Place of Birth <br /> Sex Color <br /> FATHER MOTHER <br /> Maiden <br /> Name <br /> L /ias JANE' Name <br /> Residence Residence d e <br /> a f <br /> Birthplace �, Birthplace d f e,�, <br /> ar <br /> Occupation >?.4 r D p r. Occupation <br /> Date of Record <br /> And I do hereby certify that the foregoing is a true copy from said records. <br /> WITNESS my hand and the GREAT-SEAL OF THE COMMONWEALTH at Boston <br /> on this f day of I 2�y 4• d 7 A.D. 19 f <br /> Kms`-AR .f.. .CROb" <br /> Secretary of the Commonwealth <br /> q <br /> { <br /> Year `.. . . <br /> Vol. ........... /.. .................. <br /> Page ............(...� <br /> ....................... <br /> � G <br /> r �� �� No. ................... •.................... <br /> yw.�GC/LGR. <br /> FEE 50 VENTS � <br /> OrFrom Page 12 F <br /> f <br /> r <br /> r <br /> y <br /> _ <br /> , <br />