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
|
Nov 19, 1888 | - Kinder,
- M
- 4
| W | - Nov 1, 1888
- Hamilton Township
|
- 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
|
- H.E. Kinder
- H. E. Tull
- Hamilton Township
| - Peter Kinder
- Farmer
| - Mrs. J. L. Luke, Pawnee, Harrison County, Missouri
- Mrs. J. L. Luke, Pawnee, Harrison County, Missouri
- Same
|