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
|
10/10/1888 | - Frankie F. Blakely
- female
- eighth
| white | - 10/06/1888
- Daviess Co.
|
- 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
|
- Sarah C. Blakely
- Brady
- Daviess Co.
| - J. M. C. Blakely
- Farmer
| - A. F. McFarland Gallatin, MO
|