# 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 1. live-born 2. 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!