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ebe commoutueaItb of JuRoatbulietto R <br /> = OFFICE OF THE SECRETARY (CITY OR TOW' rKING THIS RETURN) <br /> m (COUNTY) DIVISION OF VITAL STATISTICS <br /> 1 0...........it 01....... STANDARD Registered No ..... <br /> (CITY TOWN) CERTIFICATE OF BIRTH <br /> a Q.Ls L w�www• J(if birth occurred.in a hospital or institution, <br /> NO.......... `..A.../.. .... ... ........................._...__......................WARD give its NAME instead of street and number) <br /> 2 FULL NAME OF CHILD.....r. /4.Y.../YL�.......yC..o...T.T........... .y PES { If child is not yet named,make <br /> •••. .......;.... supplemental report, as directed <br /> 38ex W4 f,' 4 (a)Twin,triplet or other.,.... I5 Born IYEorSTILLBORN 6 Date Ate' A <br /> -If plural O_' _ of Birth•........ . !�* " /r <br /> �..... �f�K ................. <br /> 3-Color Q Births (b) Number,in order of birth.............I ..... ..............................( �' ) <br /> (MONTH) (DAY) (YEAR) <br /> 7 FATHER 13 MOTHER <br /> FULL MAIDEN <br /> NAMENAylE...... ...'.'-••• f i....... ... ......... ............ <br /> d <br /> PRESENT <br /> .:...................................................:.................................... NAME........... Sf� ......................:.............................. <br /> B 14 <br /> RESIDENCE, NO. ... ......................................................STREET RESIDENCE, NO...... ....... <br /> }}�//'' II'' �.j.�!xRrrz <br /> CITYORTOWN...........................................STATE................,... CITYORTOWN......,•!''�i�i ! .STATE... <br /> 9 . 10 15 16 ,. <br /> COLOR I AGE AT LAST COLOR I AGE AT LAST <br /> OR RACE.............................. BIRTHDAY.......................(YEARS) OR RACE......L'................... BIRTHDAY'........f:...`I...".:..(YEARS) <br /> 11 17 <br /> PLACE PLACE <br /> OF BIRTH..........:............................. OF BIRTH..................... ................ i........................ ' <br /> (CITY OR TOWN) (STATE OR COUNTRY) (CITY OR WN) (STATE OR COUNTRY) ' <br /> 12 iB <br /> OCCUPATION......................................................................... OCCUPATION.....K.10.tt...4 111 <br /> ......................... <br /> SIGNATURE <br /> SIGNATURE OF <br /> ATTENDANT AT BIRTH........ .................... .�.... .��.... � , <br /> ('Physician, parent or other,*etc.)'..... <br /> ADDRESSNO......�......................................................................STREET...........(.;. !'I. "F .......................................... <br /> [� 99 (City or 'Gown) <br /> DATE.......1. ............ ....... ....../.9.... .Y....,.DID ABOVE NAMED PERSONALLY ATTEND THE BIRTH?....11/l4rff.�........, <br /> (\Innlhl ay .(fear) <br /> 20 RECEIVED AT OFFICE OF CITY OR TOWN CLERK.......:............. . l. .... ... ....f...................../...� �..,. / . � <br /> .. .. ... <br /> (.Ionlh) (liar) (Yfar).. <br /> 21 A TRUE COPY ATTEST: ...................................................... ........................_:,... '..`Z(!.........-! ....... ... ..: <br /> (Registrar) <br /> I,the undersigned,hereby certify that I am the Town Clerk of the Town of Mashpee;that as such,I have custody of the <br /> records of births,deaths and marriages,as required by law to be kept in my office;and I do hereby certify that the <br /> above is a true copy from said records. <br /> WITNESS:My hand and the SEAL OF THE TOWN OF MASHPEE <br /> A TRUE COPY ATTEST: AT MASHPEE,MASSACHUSF�TTC <br /> Deborah F.Dami <br /> Mashpee Town Clerk <br /> i <br /> ' le ,> <br /> - <br />