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HEARNAP — Part 42
Page 208
208 / 705
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: V5 647-70 —" COMMONWEALTH OF VIRGINIA.” Man aly
—_— C __ APPLICATION LICATION FOR A CERTIFIED copy OF A BIRTH RECORD Sika Vu" se
, eat a Settva Menali ; } Bo Nor waire E
2 oth Octeber @ 14 7HY sx Male Gerace | White
{, SO Sain | Mont Va. VIRGINIA
| 4 aie ENCLOSED 55 AOS SPN. ;
; ; Uy iT U.- vatye !
5 oF act MAME Ute: or Leu ce Kaien iawn. i 0020
6 NAME OF Privsician on lor.
i MIDWIFE AT BIRTH wn KNOWN) -_—_——,_ _
7 oan oeconata (F ANY) WHERE Home
| HAS NAME EVER GEN CHANGED IF SO, WHAT WAS in.
& omer THAN By MARRIAGE? YES NO Ae ORIGINAL MANE? —
) ARE YOU THE PERSON tf NOT, WHAT IS
9 amen IN LINE 1? YES (NO ox YOUR RELATIONSHIP? «6 other 2 8. O
+E E veer,
SPECIFIC PURPOSE FOR WHICH THUS
10 CEATIFAD Cory is REQUESTED Pane PA A VERIFIED BY
Gna oF « * * «
11 Revryss oF By nan 1. Ko
| 13 Sao zie cone ~ 24s inure mene
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