Part 86, page 209
Document date 17 March 1976
FBI 164-81, Vault Part 86 p. 209 (DB Cooper-38099), Form, dated 17 Mar 1976 — cooper.theunsolved.net/parts/Cooper-Part-86/pages/209
Transcript
The scan is the source; the transcript is machine-generated from it.
Department of Commerce Bureau of the Census
CERTIFICATE OF BIRTH COMMONWEALTH OF VIRGINIA DEPARTMENT OF HEALTH BUREAU OF VITAL STATISTICS
Registered No. 6691 62
1. PLACE OF BIRTH (a) County: Arlington Registration District No. 20 For use: [illegible] (b) Magisterial District: ___ (c) City or town: ___ (d) Name of hospital or institution: Arlington Hospital (e) Is place of birth within corporate limits? ___
2. USUAL RESIDENCE OF MOTHER (a) State: Virginia [number] 0.2190 (b) County: Fairfax (c) City or town: Norfolk [guess: Norfolk] - [illegible] (d) Street no. ___ (e) Is place of residence within corporate limits? Yes
3. Full name of child: Jerry Arthur Cooper 4. Sex: Boy 5. Twin or Triplet: [blank] 6. If so, born 1st, 2nd, or 3rd: [blank] 6. Months of pregnancy: 9 7. Is mother married to father of child? Yes 8. Date of birth: Feb 4 [guess: 1945] Month by name, Day, Year
FATHER OF CHILD 9. Full name: [obscured] 11. Color or: [obscured] 12. Birthplace: [obscured] 13. Usual oc[cupation]: [obscured] 14. Industry: [obscured]
21. Children born to this mother: 0 (a) How many other children of this mother are now living? 0 (b) How many other children were born alive but are now dead? 0 (c) How many children were born dead? 0
22. I hereby certify that I attended the birth of this child who was born alive at the hour of 3:35 p.m. on the date above stated and that the information given was furnished 24. Were eyedrops used? Yes
Attendant's own signature: [illegible] Physician, Midwife, or other: [signature] Date signed: 2/8/45 Address: [illegible] - [guess: N. Som...] [illegible]
25. FEB. 14, 1945 Date rec. by reg.
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NOTICE OF VERIFICATION
FOR OFFICIAL GOVERNMENT USE ONLY (To Be Retained by Using Agency)
This is to verify that the foregoing is a reproduction of the original record on file in the Bureau of Vital Statistics, Virginia Department of Health, Richmond, Virginia.
JAN 7 1976 Date Issued
Deane Huxtable DEANE HUXTABLE, State Registrar
DB Cooper-38099