SCHEDULE Part I Certificate showing re-registration of birth, produced to me this day of 19 , showing father’s name as A. B.
(signed)
Officiating Minister
Officer in charge of diocesan record office or as the case may be.
Diocesan Registrar
Section 1.

Part II Certificate of Baptism
I hereby certify from the records of the parish of (1) that (2) was baptised according to the rites and ceremonies of the Church of England on the day of in the year of Our Lord 19
(signed)
Rector, vicar, curate, minister of
or
Chief Officer of the diocesan record office of the Diocese of
or
Registrar of the Diocese of
The particulars to be inserted in the numbered spaces of the above form are:—
(1) The name of the parish or other place of which the register of baptisms in question is or was the register. If the place is not a parish the word parish is to be struck out and other appropriate words are to be substituted therefor.
(2) The Christian names of the baptised person as recorded in the entry followed by the surname of his father as recorded in the entry or if more than one such surname is so recorded or if his mother appears from the entry to have borne a different surname at the date of his baptism, such one of those surnames of his father or mother as the applicant may request. If an annotation has been made against the entry in the register, by virtue of section one of this Measure the surname is to be that recorded in the annotation. If there is no such annotation and no entry appears in the column for the father’s name in the register the surname to be inserted is the surname of the baptised person’s mother appearing from the entry to have been used by her at the date of baptism or, if more than one such surname is so recorded, such one of them as the applicant may request.
Section 2.