- 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
|
- SUSAN DALTON
- SUSAN GARRISON
- BIBLE GROVE, MO
| - JASON DALTON
- Farmer
| - J. B. BRIDGES, MD BIBLE GROVE, MO
|