| What is the full name of child? | Burrell, Bernard Frederick |
| When was the child born? | 15th May, 12 |
| Where was the child born? | 51 Keith Street |
| Male or Female | M |
| Are the parents married? | Yes |
| Full name of Father | Francis Wm. Burrell |
| Occupation of Father? | Laborer |
| Full Maiden Name of Mother | Sarah Ann Bond |
| If she has been more than once married give names of former husband, or husbands | |
| Where were the parents married? | Northampton, England |
| When were they married? | 19th January, 1898 |
| If not married give full Name of Mothe | |
| Is she single or a Widow? | |
| What is her occupation? | |
| Name of Physician attending | Day-Smith |
| Your relation to child | Mother |
| Were you in house at time of Birth? | Yes |
| Certified by | Sarah Ann Burrell |
| Address | |
| Date | |
| Remarks | 6th June, 12 |
Source: Archives of Ontario; Series: MS929; Reel: 231
Source: Ancestry.com. Ontario, Canada Births, 1869-1913