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
|
Aug 26 1885 | - St. Clair
- Female
- Third
| White | - Aug 17th 1885
- Washington Twp
|
- 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
|
- St. Clair, Mary Frances
- Turner
- Washington Twp
| - St. Clair, John Thomas
- Farmer
| - Mrs. Clips Turner & White, Neeper, MO
- S. Neeper, MD, Kahoka MO
- DO
|