DATE OF BIRTH:_______________ TIME OF BIRTH:___________________________________

ADDRESS OF BIRTH:_______________________________________________________________

CHILD'S NAME:______________________________________SEX OF CHILD: ______________

MOTHER'S NAME:_________________________________________ AGE: __________________

ATTENDANT'S NAME:______________________________________________________________

ATTENDANT'S ADDRESS:___________________________________________________________

ATTENDANT'S TITLE:______________________________________________________________

WITNESSES OTHER THAN ATTENDANT: (If any)

1.
NAME:_______________________________________________________________________
ADDRESS:___________________________________________________________________
RELATIONSHIP TO MOTHER:________________________________________________


2.
NAME:_______________________________________________________________________
ADDRESS:___________________________________________________________________
RELATIONSHIP TO MOTHER:________________________________________________


I,____________________________, do hereby swear that all information given in this document is true and accurate to the best of my knowledge.

Date:_______________________________________________________

Attendant Signature:__________________________________________

Attendant Name (Printed)______________________________________

Notary Signature:____________________________________________ (NOTARY SEAL)

Leather Dupris, Notary Public
Commonwealth of Massachusetts
Commission Expires_______________20_____