APPLICATION FOR ENTRY IN THE REGISTER OF BIRTHS

Part I

(name of health institution)
No. __________
Date: 28 VI 1974

Birth Register running number: 2512/74

TO THE REGISTRAR OF THE SETTLEMENT OF

Novi Sad

Pursuant to paragraph 1 of Article 6 of the Act on Civil Registers, we hereby report, for entry in the Register of Births, the following case of birth:

1. Day, month, year and time of birth

28 June 1974, at 13:25

2. A child was born

1. male sex

2. female sex

3. live-born

4. stillborn

Handwritten entry: Miletić Milivoj

3. Place of birth, street and number

Novi Sad, Branimira Ćosića 37

4. How many children were born in this delivery

one

5. How many children the mother has borne to date (including this child)

Enter number of children:

• total: 1
• live-born: 1
• stillborn: /

6. How many of those children are alive

Enter number of children: 1

7. How many children the mother has borne in this marriage (including this child)

Enter number of children:

• total: 1
• live-born: 1
• stillborn: /

If the child was born out of wedlock: X

8. Place and date of conclusion of marriage

9. Which marriage in order for the mother

• not married: 0
• first: 1
• second: 2
• third and more: 3
• unknown: 9

10. DATA ON THE FATHER

Surname and surname before marriage

Given name

Place and date of birth

Citizenship

Place of entry in the citizenship register

Residence and home address

Occupation

Ethnicity (narodnost)

12. Father's education (highest completed school)

• no schooling (including grades 1-3 of elementary school)
• incomplete elementary school (grades 4-7 of elementary school)
• elementary school (8 grades)
• school for qualified workers and other vocational personnel
• secondary school
• faculty, higher school and college
• no data on the father
• unknown

11. DATA ON THE MOTHER

Surname and surname before marriage
Miletić

Given name
Cvita

Place and date of birth
Bila Vlaka, 23 III 1931

Citizenship
Yugoslav

Place of entry in the citizenship register

Residence and home address
Novi Sad, salaš (farmstead)

Occupation
housewife

Ethnicity (narodnost)
Croatian

13. Mother's education (highest completed school)

• no schooling (including grades 1-3 of elementary school): 0
• incomplete elementary school (grades 4-7 of elementary school): 1
• elementary school (8 grades): 2
• school for qualified workers and other vocational personnel: 3
• secondary school: 4
• faculty, higher school and college: 5
• unknown: 9

NOTE

An extract from the Marriage Register is attached, or, for a child born out of wedlock, an extract from the Register of Births for the mother, running no. __________

(Signature of the head of the institution)
(Official seal)
(Signature of the person who provided the data)

Part II

STATEMENT ON DETERMINING THE CHILD'S PERSONAL NAME

1.

We, the undersigned parents, declare that we have jointly determined the child's personal name as:

At ____________________
On ____________________

Father's signature ____________________
Mother's signature ____________________

Statement taken and certified by: ____________________
Official seal

2.*

I / we, the undersigned parent, father* - mother*, declare that we, the parents, have agreed to determine our child's personal name as:

Miletić Milivoj

At Novi Sad
On 28 June 1974

Parent's signature ____________________

Statement taken and certified by: ____________________
Official seal

Part III

STATEMENT OF ACKNOWLEDGMENT OF PATERNITY OF A CHILD BORN OUT OF WEDLOCK

1. ACKNOWLEDGMENT OF PATERNITY

I hereby irrevocably declare that I acknowledge the paternity of the child born out of wedlock reported in Part I of this application, and I request the registrar to obtain the mother's consent to this acknowledgment and then to enter the acknowledgment of paternity in the Register of Births.

My personal data are:

Surname

Given name

Place, day, month and year of birth

Citizenship

Place of entry in the citizenship register

Residence and home address

The statement has been read and explained to me, and as I have no objections, I sign it.

At ____________________ on ____________________

(father's signature)

Statement taken and certified by:

Official seal ____________________
(registrar)

2. MOTHER'S CONSENT TO THE ACKNOWLEDGMENT OF PATERNITY

I hereby declare that I consent to the above acknowledgment of paternity made by ____________________

At ____________________ on ____________________

(mother's signature)

Statement taken and certified by:

Official seal ____________________
(registrar)

Part IV

OFFICIAL NOTES

1. The parents' personal data were established by inspection of the Marriage Register* / Birth Register* kept by this registrar under running no. __________ for the year __________.*

2. The parents' personal data were established by inspection of an extract from the Marriage Register* / Birth Register* of the place Bila Vlaka, running no. 38, for the year 1931.*

The child was entered in the citizenship register kept by ____________________

under ordinal no. ____________________ on page ____________________, and registered in the alphabetical index kept with that register under the letter ____________________ under ordinal no. ____________________.*

4. A report on the birth registration was sent to the Municipal Assembly ____________________

to the local office ____________________ under no. ____________________ on ____________________

for entry of the child in the citizenship register.*

____________________ 19____

Registrar,

* Cross out as appropriate.

Certification page

The photocopy is true to the original!