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<br /> Form R-54. 1OM-4-59-925160
<br /> •
<br /> of Aasoarhnsrtto N° 268626
<br /> JOSEPH D. WARD
<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 /> d 11 Wd LC7 Cid ral y r
<br /> and that the following is a true copy of so much of said record as relates to said birth, namely:--
<br /> Name 11 An d h I)IJ d/
<br /> Date of Birth
<br /> Place of Birth C,
<br /> Sea / le kA A /e Color
<br /> FATHER MOTHER
<br /> Name Maiden
<br /> re drIC k Oddher Name O /'CCIJ 06 O �j J
<br /> Residence e e Residence f
<br /> F P
<br /> Birthplace 00'r Birthplace �.P Joe e
<br /> Occupation L C1 h �. �. Occupation -- —
<br /> Date of Record x
<br /> f
<br /> nd 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 / G day of N kj �P�- 19 �+
<br /> JOSEPH D. WARD
<br /> Secretary of the Commonwealth
<br /> � Fy11911
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<br /> ' Year ........:�.... .. .. ...........
<br /> Vol. .................. ..............
<br /> z �v : Y 1 wP yry
<br /> Page .......................y.. .......
<br /> No. ............................... ..............
<br /> FEE $1.00
<br /> From Page 12
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