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
|
10/1/1884 | - Wittman, Bertha Adelphe
- F
- 2
| | - 9/14/1884
- Crystal City
|
- 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
|
- Wittman, Rosalie
- Yoezle
- Crystal City
| - Wittman, Adolphe
- Glass Worker
| - T B Taylor, MD, Crystal City
- T B Taylor, MD, Crystal City
- T B Taylor
|