TT FORM co0 (fev, Mod;
TRUST TERRITORY CF THE PACIFIC ISLANDS
QEPARTMENT GF HEALTH SERVICES
NOTICE CF NAME OF CSiTrI2
A
7] 3CY {_] GIRL wwo was not ver a€EM Mamta was BORN TO:
AGORESS CF
PARENTS:
(NAME OF MOTHER
PLACE CF SIRTH
DISTRICT
MUNICIPAL ITY
VILLAGE
NAME CF FATHER
A“ NOTIFICATION OF SIRTH® WiLL SE SENT TC THE MOTHER, IF THE FCLLCWING FORM 1S PROPEALY FILLES IN AND GI-EN TO THE
VITAL REGISTRATION REPRESENTATIVE FCR THAT AREA OR THE DISTRICT OIRECTOR OF HEALTH SERVICES,
7
THIS FORM MAY 8€ SENT TO THE OISTRICT OIRECTOR OF HEALTH SER. ICES THROUGH ANY HEALTH AIOE, NURSE OR MEDICAL CFFICER
DATE RECEIVED
SIGNATURE (ONSTRICT DIRECTOR OF HEALTH SERVICES}
TT Form S6Q (nev. 1068)
CERTIFICATE OF
PARENT OR OTHER RELATIVE
—
ds
rary
a
|. 8d ee ee eee Nt Nt ee ee Ln ee ewe tw tw tw ww. Oe Lo CB0Y
(STATE RELATIONSHIP TO CHILD, AS "FATHER OR MOTHER”!
(|GzR:
(cnécx ome)
BORN CN LL LB LT Oe m oun HEREBY CERTIF
mHap
(pate)
(Ptacz)
THAT THE PARENTS OF THE CHILD HAVE AGREED ON THE FCLLOWING NAME FOR HIM OR HER (CROSS. OUT ONE) AND REQUEST THAT THIS 8£
ENTERED UPON THE CHILO*S BIRTH CERTIFICATES
MAME OF CHILD
19
gate
SIGHATURE OF PERSON NAMED ABOVE
CERTIFICATE AND CATE OF
VITAL REGISTRATICN 2S>R2SENTATIVES
I GWEAR THATTHE ABOVE WAS SIGNED PERSONALLY SY THE PERSON NAMEG THEREIN AND f AM SATISFIED THAT IT REPRESEKTS HIS
OR HER TRUE OESIRE,
SIGMATUBE OF
VITAL AEGISTAATION AREPRESENTAT! VE
SIGNED ANO SWORN TO 8EFORE ME THIS ~~ —-——+—.——-— aYOF 2 LLL LLL LLB.
SIGMATURE OF OFFICIAL
TITLE
AE
CONVENTENT,
AUTHOAEZED TO ADMINISTER OATHS
nn
OFFICIAL AUTHORIZED
THE PARE NT OR OTHER RELATIVE MAY SWEAR TO WIS OR WER CLATIBICATE BEFORE AMY
|
AMD THE W OTHE CERTIFICATE ANO CATH OF
;
eae
TO AQMINISTER OATHS,
VITAL REGISTRATION REPRESENTATIVE MAY FE OMITTED.