"Application for Statement of Original Registration of Birth by the Adult Child of a Deceased Adoptee" - New Brunswick, Canada

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Application for Statement of Original
Registration of Birth by the Adult Child
of a Deceased Adoptee
Department of Social Development
POST ADOPTION DISCLOSURE SERVICES
The information collected on this form is collected under the authority of the Family Services Act and will be used to
fulfil the requirements of this Act for the release of information relating to adoptions.
Questions: call 1-844-851-0999 (toll-free in Canada and the U.S.)
Email:postadoptionservices@gnb.ca
To submit your form
Office Use Only
Mail: Post Adoption Disclosure Services
Department of Social Development
Date Received:
P.O. Box 6000, Fredericton, N.B. Canada
E3B 5H1
Applicant Identification and Proof of Death Requirements
If you (the applicant) were born in New Brunswick, please provide a clear copy of your birth certificate and
one piece of current government-issued photo identification with your application.
If you (the applicant) were born outside of New Brunswick, please provide a clear copy of your long form
birth certificate, which must include the name(s) of your parent(s), and one piece of current government-
issued photo identification with your application.
Your photocopied identification must be verified and signed by a witness (see page four for guidelines). If
the copy is not clear, the application will be returned to you.
Proof of Death: For deaths occurring in New Brunswick, a funeral home certificate of death or a death
certificate is required. For deaths occurring outside of New Brunswick, a death certificate is required.
Application for Statement of Original
Registration of Birth by the Adult Child
of a Deceased Adoptee
Department of Social Development
POST ADOPTION DISCLOSURE SERVICES
The information collected on this form is collected under the authority of the Family Services Act and will be used to
fulfil the requirements of this Act for the release of information relating to adoptions.
Questions: call 1-844-851-0999 (toll-free in Canada and the U.S.)
Email:postadoptionservices@gnb.ca
To submit your form
Office Use Only
Mail: Post Adoption Disclosure Services
Department of Social Development
Date Received:
P.O. Box 6000, Fredericton, N.B. Canada
E3B 5H1
Applicant Identification and Proof of Death Requirements
If you (the applicant) were born in New Brunswick, please provide a clear copy of your birth certificate and
one piece of current government-issued photo identification with your application.
If you (the applicant) were born outside of New Brunswick, please provide a clear copy of your long form
birth certificate, which must include the name(s) of your parent(s), and one piece of current government-
issued photo identification with your application.
Your photocopied identification must be verified and signed by a witness (see page four for guidelines). If
the copy is not clear, the application will be returned to you.
Proof of Death: For deaths occurring in New Brunswick, a funeral home certificate of death or a death
certificate is required. For deaths occurring outside of New Brunswick, a death certificate is required.
PART 1:
Applicant Information
First name
Middle name(s)
Current surname
Maiden names (if applicable)
Date of birth
Was the applicant born in New Brunswick?
Year /Month /Day
Yes
No
Birth registration number (from birth certificate)
If not, a long form birth certificate including the
name(s) of the parent(s) and place of birth must be
provided.
Mailing address: Apartment number/Street number and name
City/Town
Province/State
Country
Postal/Zip code
Home telephone number
Work telephone number
Cell telephone number
Country code (
)
Country code (
)
Country code (
)
(
)
(
)
(
)
Email address
PART 2:
Adoptee’s Birth Information – Complete all known information
Adoptee’s birth name
Adoptee’s date of birth
Adoptee’s place of birth
Year /Month /Day
Birth registration number (from
birth certificate)
Adoptive mother’s full name
Adoptive mother’s date of birth
Year/Month/Day
Adoptive mother’s maiden name, if applicable:
Adoptive father’s full name
Adoptive father’s date of birth
Year/Month/Day
2
Declaration
I understand and acknowledge the following:
I am identifying myself as the adult child of a deceased adoptee.
• The Statement of Original Registration of Birth cannot be released until after the adoptee has
turned 19.
• If a disclosure veto exists against the release of an individual’s identifying information, that
information will not be released until one year after their death.
➢ If a veto is not filed and you are the adult child of a deceased adoptee, their information
may be released to you.
_______________________________
_____________________________
Signature
Date
_______________________________
_____________________________
Signature of witness
Date
If your information changes, contact Post Adoption Disclosure Services to update your file.
Driver’s Licence
ID that is included:
Birth certificate
Passport
Other
* Remember to have a witness verify your photocopied identification documents
3
Information about the Witness
PLEASE NOTE: FAILURE TO HAVE A WITNESS VERIFY YOUR PHOTOCOPIED IDENTIFICATION
DOCUMENTS WILL MEAN THAT YOUR FORM CAN NOT BE PROCESSED.
For your form to be processed it must be accompanied by a photocopy of two valid pieces of government-
issued identification: a birth certificate and one piece of current government-issued photo identification.
Your photocopied identification must be verified and signed by a witness. An acceptable witness is a
Commissioner of Oaths, a Notary Public or a designated professional.
• A Notary Public can usually be found in a law office.
• A Commissioner of Oaths may be found in the offices of:
➢ Real estate agents or general insurance agents
➢ Professional accountants
➢ Rural post offices
➢ Municipal offices
➢ Police officers
Note: An appointment may be required and there may be a fee for this service.
• For the purposes of witnessing your signature on Part 1 and for verifying the photocopy of your
identification documents, a designated professional is considered to be one of the following:
➢ Dentist/Medical doctor/Chiropractor/Optometrist/Psychologist
➢ Lawyer
➢ Minister of religion
➢ Pharmacist
➢ Principal or teacher at a primary or secondary school
➢ Judge/Magistrate/Police officer/RCMP officer
➢ Justice of the Peace
➢ Postmaster
➢ Professional accountant who has a designation
➢ Signing officer or manager at a bank, credit union, trust company, or other financial institution
➢ Senior administrator, teacher, professor at a community college or university
➢ Veterinarian
➢ Social worker
➢ Chief of First Nations band
➢ Funeral director
➢ Nurse practitioner/Registered nurse
➢ Member of Parliament
➢ Member of the Provincial Legislature
➢ Municipal official
➢ Official of a federal government department or provincial government department, or one of its
agencies
➢ Official of an embassy or consulate
➢ Professional engineer
***IMPORTANT: Your witness must sign and date the photocopy of your identification. Your witness
must also provide contact information, including her or his occupation or designation, place of
employment, address and a daytime telephone number where she or he can be reached. A
Commissioner of Oaths must provide a commission expiry date.
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