Date of Abstract ___________         Abstracted by_____________________

 

 

                 BIRTH RECORD ABSTRACT

 

 

Repository_____________________________________________________

Address_______________________________________________________

Source _________________________________Volume_____ Page_______

 

Full Name_____________________________________________________

Color and Sex__________________/_______________________________

Names of other children living______________________________________

_____________________________________________________________

Number of child of this Mother___________Number now living___________

Number born alive but now dead_________ Stillborn___________________

Legitimate/Illegitimate_________________ Multiple birth_______________

 

Full name of Father____________________________________Age_______

Birthplace of Father______________Occupation_______________________

 

Full maiden name of Mother______________________________Age______

Birthplace of Mother______________Occupation______________________

 

Hour_______Day_______Month________Year_________of this child’s birth

Town/Township/City/County of birth________________________________

Name of Midwife or Physician______________________________________

Residence of the last person named_________________________________

 

Date of Certificate or Affidavit_____________________________________

Name of Health Officer or clerk_____________________________________

Residence of last person named____________________________________

Date of Registration_____________________________________________

Any other important information____________________________________

Extra evidence/abstracts of supporting evidence/date original made________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

Address of person abstracting this record and other contact and relationship

Information___________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________