Birth certificate Parents:

Citizen_____________________________ Father_______________________________________
(surname, (surname,

___________________________________ ____________________________________________
full name) full name)

Was born ___________________________ Nationality____________________________________

(year in words and in figures,

___________________________________ Citizenship____________________________________
month and date)

Place of birth: city, urban, village Mother _______________________________________

(surname,

____________________________________ _____________________________________________
full name)

District______________________________ Nationality____________________________________

Region______________________________ Citizenship_____________________________________

Were of a corresponding record was made Place of registration_____________________________

in a birth registry on: (the name and location of the authority that

4 October 1997
_ _____________________________________________
issued the document)

Date of issue «10» October 1997

Head of the department for recording civil status acts

Signature_________

L.S. : State Seal

Pervomaysk City Council of People's Deputies of Ukraine
Pervomaysky district of Mykolaiv region
National emblem of Ukraine

І-ФП №017345