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
|
Apr. 16, 1889 | - Lena Garland
- Female
- 5th
| White | - Mar. 22, 1889
- Carthage, Mo.
|
- 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
|
- Fannie ?. Garland
- Fannie ?. Faudette
- Carthage, Mo.
| - Edward Garland
- Clerk
| - Robert F. Brooks. Carthage, Mo.
- Same
|