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
|
DEC 11 83 | - LILLIE MAMIE KEMPER
- Female
- 1ST
| White | - NOV 10 1883
|
- 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
|
- LENA KEMPER
- LENA MULLINS
| - THOMAS KEMPER
- Farmer
| - G L KNAPP MT VERNON
- SAME
- SAME
|