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
|
oct 2 1884 | - Viers,
- Female
- Eighth
| White | - Sept 30th 1884
- Washington Twp
|
- 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
|
- Viers, M. E.
- Erwin
- Washington Twp
| - Viers, Walter
- Farmer
| - w. C. McReynolds, MD, Fairmont, MO
- DO
- DO
|