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_____ Number

Date __________________________________________
1902 (thousand _________________________) year
_______________ month ___ _______________day

The undersigned registar has been published _____________ in front of


___________________________ whose occupation is ____________________
___________________place of residence_________________
Signed ______________________________person_______________________

Family name and first name _______________________________


Faith and religion _______________________________________
Occupation____________________________________________
Place of residency________________________________________
Place of Birth___________________________________________
Age_____ ______________________________ year

family name and first name _______________________________

Fathers family name and first name, occupation, place of


residency____________________________________________________________________
___________

Mothers family name and first name, occupation, place of residency


____________________________________________________________________________
________________________________

Place________________________________
Time_____________ (thousand_________________________) year
Month___________________ day of________________hour______________
Reason______________________________________________
notes________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Conclusion___________________________________________________________________
__________________
Approved by______________________________________________________________

__________________________ _______________________
Registar Notary

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