Date of Return (Month/Day/Year) | - Name of Child
- Sex
- No. of Child of this Mother
| Race or Color | - Date of Birth
- Place of Birth
|
Feb 12 1884 | - Elvira Kenney
- female
- nine
| white | - Janry 13 1884
- NE of Belton 5 m
|
- Full Name of Mother
- Maiden Name of Mother
- Residence of Mother
| - Full Name of Father
- Occupation
| - Name and Address of Medical Attendant
- Name and Address of Person making Certificate
- Returned by
|
- Elvira Keeney
- Campbell?
- Holt Co Mo
| - Isaac Kenney
- farmer
| - Jas W Spruill Belton Mo
- Jas W Spruill
- Jas W Spruill
|