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Aiden Name) First Father s Name State File Number 110Date Of Birth (Mo., Day, Yr.) County Of Birth Middle Date Of Birth (Age) State Of Birth Middle First Last Last Date Of Birth (Age) State Of Birth Item Omitted Or In Error Birth Certificate Shows I hereby declare upon oath that the above statements are true to the best of my knowledge and belief. Should Be Present Address Of Registrant (Street or R.F.D. No., City, Town, State, Zip) (signature of Registrant or parent) Subscribe.
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