WARNING: It is illegal to duplicate this copy by photostat or photograph. See reverse side (Fee for this certificate, $ 1.00) No 242468 1. PLACE OF BIRTH COMMONWEALTH OF PENNSYLVANIA File No. D5783-03 DEPARTMENT OF HEALTH County usquehanna VITAL STATISTICS Date Filed Nov. 27 19 67 CERTIFICATION OF BIRTH Township Hallstead Borough Date of 2. Birth Aug. 31 1903 City (Month, day, year) 3. Name of Child Clarence Wilson Chamberlin 4. Sex Male 5. Name of Father Charles Summer Chamberlin Maude Ethel Brown 6. Maiden Name of Mother Thomas W.Georgesh MD This is to certify, that this is a correct certification of birth as filed in the Vital Statistics office, Pennsylvania Secretary of Health Department of Health, Harrisburg. NOV 30 1967 Date Issued