Moorish Science Temple of America

Record of Live Birth

Let it be known by all men that at __________A.M./ P.M. on
____________________of the Hijiri Calendar, corresponding to
____________________of the Gregorian Calendar, occurred the live birth/
nativity of _______________________________________, a male/ female child,
at ______________________[City], in the territory and/or adjoining island of
______________________ in Al Moroc/ Amexum (America).

WHEREFORE the below signed witnesses do attest to and verify all claim to this
live birth/ nativity by these parent-parties:
Mother:__________________________________ and
Father: __________________________________ by their union.

For these witnesses, knowledge of the below facts accompany these claims of this
live birth/ nativity with this truth communication claim by the live-birth party:

:Photo :Fingerprint :Blood/ Saliva

____________ ____________ ____________

Witness 1:______________________________________
Witness 2:______________________________________
Witness 3:______________________________________
Seal