Part 1 particulars to be entered where the record of the birth was created on or before 30th September 1973

Birth Registered in the District of

in the Superintendent Registrar’s district of

in the county of

Entry number

Date and Place of birth

Name (if any) (child’s forename(s))

Sex

Name and Surname and Dwelling-place of Father

Name and Surname and Maiden Surname of Mother

Rank or Profession of Father

Signature, Qualification and Residence of Informant

When Registered

Signature of Registrar

Baptismal Name if added after Registration of Birth and Date