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. 1, 1884 | - Berthe Adelphe Wittman
- Female
- 2
| | - Sept. 14, 1884
- Crystal City,MO
|
- 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
|
- Rosalie Wittman
- Rosalie Yoez[l or t]e
- Crystal City, MO
| - Adolphe Wittman
- Glass Worker
| - T. B. Taylor, MD
- Crystal City, MO
-
|