Birth ID:                    

Certificate Location:        
Certificate Number:          

Birth Location:              
Birth Date:                  

Name:                        
Immigrant ID:                
Sex:                         

Parents' Home Address:       

Father's Name:               
Immigrant ID:                PRET-15NOV1907-3-60-0020 LRTC-14JUL1912-3-19-0002 
Birth Place:                 
Occupation:                  

Mother's Name:               
Immigrant ID:                HAVR-09JAN1913-3-E-0025 
Birth Place:                 
Occupation:                  

No. of Children Born:        
No. of Children Now Living:  

Parents' Marriage Date:      
Parents' Marriage Place:     


Comments:
                             filed in Delayed Book 3, p. 944