ENGLISH EXTRACT TRANSLATION OF __________________ LANGUAGE

BIRTH CERTIFICATE

Name of Registered Child: __________________________________________

Date of Birth: __________________________________________

Place of Birth: __________________________________________

Father of Child: __________________________________________

Age of Father: __________________________________________

Nationality of Father: __________________________________________

Mother of Child: __________________________________________

Age of Mother: __________________________________________

Nationality of Mother: __________________________________________

PATERNAL GRANDPARENTS ______________________________________

______________________________________

MATERNALGRANDPARENTS ______________________________________

______________________________________

PLACE and DATE REGISTERED: ____________________________________

____________________________________

Volume, Page and Number: ____________________________________

Name of Judge (if delayed registration): ______________________________

WITNESSES: _____________________ & ____________________________

DATE & PLACE THIS COPY ISSUED: ________________________________

I, ______________________________, attest to my competency to translate from

___________________________ to English, and I certify that this is a correct English

translation of all pertinent information from the _______________________ original.

____________________________________ Date: _______________________