[Ger-Poland-Volhynia] Civil birth registration

[gswilson19 at aol.com]

Can anyone on the list read Old German Script?  I have a copy of a Civil registration of a birth record.  There was a piece of tape going down the middle of some most of it.  I am trying to make out which city it is from and where the parents were born.  If is scan it, would someone be able to take a look a see whether they can make out the town names?
 
Thank you,
 
Gail 
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