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. ceria No. \ { e § _ Ce Certification No. d / 6 ry lax App@ation for Birth Reco@ | ($2.00 fee for Certified Copy } ‘ KA Has Name Ever Been Changed no Date of Birth Macc an, 1449 _ a Father's Name ——hee _ORovot _ Mother’s Maiden Name _b.ee _ ; oo. Did Birth Occur in San Francisco bal : Wes : : No- ~ For what purpose is this record required _—- Pas eoeT : ADDRESS IB22% 2G Crytlan dd Sreot . POSTAL ZONE FOR DEPARTMENT USE ONLY Number of Copies / Date Issued —%,, le Reccipt No. Typed ey Photo — ago A . ¥ SOL a ee ce mit p-15200 Pr Q2216 eels Re Abe neg ety te Se RATE . eee ee! eich Ua -¢ . Fas Nr Taes ¥ — re = Le Sa ny fase a of, separated py, 2 red ae ee: +