TT FORM aoU (REY,
loc)
TRUST TERRITORY GF THE PACIFIC ISLANOS
DEPARTMENT OF HEALTH SERVICES
NCTICE OF NAME CF CHILD
A
f] s0Y ((] GIRL wwe was nor ver acew marta was sonn To:
ADDRESS oF
VILLAGE
MUNICIPAL FTY
NAME CF FATHER
NAME
.
DISTRICT
PLACE CFE
0 OF
MOTHER
BIRTH
PARENTS:
A" NOTIFICATION OF BIATH® WILL SE SENT TC THE MOTHER, IF THE FCLLOWING FORM !'S PROPERLY FELLES IX AND GIVEN TO THE
VITAL REGISTRATION REPRESENTATIVE FCR THAT AREA OR THE DISTRICT OIRECTOR OF HEALTH SERVICE
THIS FORM MAY SE SENT TO THE OFSTRICT OFRECTOA OF HEALTH SER“ ICES THROUGH ANY HEALTH Ape NURSE OR MEDICAL CFFICE
DATE RECEIVED
SIGNATURE (OISTRICT OTRECTOR OF HEALTH BER vices}
TT Foam S60 (rev. 1068)
CERTIFICATS OF
PARENT OF OTEER RELATIVE
.
oo -uee ee eee ee ee ee ee eee eee eee eee ee oe
.
(STATE RELATIONSHIP TO CHILD, 2S "FATHER Of moTaER”}
(cate)
(ruace)
THAT THE PARENTS OF THE CHILD HAVE AGREED ON THE FOLLOWING NAME FOR HIM OR HER (CROSS. CUT
ENTERED UPON THE CHILD*S BIRTH CERTIFICATE:
{cnecx ome)
@NE) ANO AEQUEST THAT THIS :
NAME OF CHILO
oaTe
SIGMATUAE OF PERSOR NAMED A80 £
CERTIFICATE AND OATH OF
VITAL REGISTRATICN SETRESENTATIVE
{ SWEAR THAT THE ABQVE WAS SIGNED PERSONALLY 3Y THE ?EASON NAMEG THEREIN AND 1 AM SATISFI@D THAT IT REPRESEATS HIS
OR HEF TRUE OESIAE.
SiGMaATUME OF
VITAL REGISTRATION REPRESENTAT! VE
SIGNED ANO SWORN TO BEFORE ME THIS ~- ~~ 4 +4. OAYOF. 2 wot PL LL LLL 9.
SIGMATURE OF CRFICIAL AUTHGREBES TO AGMINISTER GaTus
TITLE
—————————
CEATIBICATE BEFGRE ANY OFFICIAL AUTHORIZED
CIF MORE CONVENIENT, THE PARENT OR OTHER RELATIVE MAY SWEAR TO WIS OR HER
FEPRESENTATEVE MAY 3€ OMETTED. |
TEGISTAATION
VITAL
OF
OATH
AND
CERTIFICATE
THE
THEN
TO AOMENESTER OATHS, AWO
gq |