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
|
April 26 1886 | - Lewis William Whetzell
- male
- second
| | - March 23rd
- Cross Timbers Tp
|
- 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
|
- Nancy Ellen Whetzell
- Wilkerson
- Cross Timbers Tp
| - Hiram William Whitzell
- Farmer
| - G. N. White J. W. White and G. W. Snow
|