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.

____________________ ____________________
Child’s left foot print Child’s right foot print
Witness 1:______________________________________
Witness 2:______________________________________
Seal
Witness 3:______________________________________