Certificate Number | 202 | | Date Issued |
Child Given Name | |
Roarch | Child Surname |
Child Sex | Male |
W | Child Race |
Date of Birth | 03 Nov 1885 |
| Place of Birth |
Father's Given Name | Hank C. |
Roarch | Father's Surname |
Father's Occupation | Produce Dealer | | Father's Nationality |
Father's Birth Place | Indiana | 36 | Father's Age |
Mother's Given Name | Jennie | Dawson | Mother's Maiden Name |
Mother's Surname | Roarch | Richland Twp Story Co IA | Mother's Residence |
Mother's Nationality | | Indiana | Mother's Birth Place |
Mother's Age | 25 | 3 | Number of Child This Mother |
Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
Returned by Name | E.H. Munk | | |