Certificate Number | 353 | | Date Issued |
Child Given Name | Vince |
Bales | Child Surname |
Child Sex | Male |
W | Child Race |
Date of Birth | 17 Jul 1886 |
Maxwell Story Co IA | Place of Birth |
Father's Given Name | D.D |
Bales | Father's Surname |
Father's Occupation | Clerk | | Father's Nationality |
Father's Birth Place | Iowa | 23 | Father's Age |
Mother's Given Name | Mary E. | Carpenter | Mother's Maiden Name |
Mother's Surname | Bales | Maxwell Story Co IA | Mother's Residence |
Mother's Nationality | | Iowa | Mother's Birth Place |
Mother's Age | 19 | 1 | Number of Child This Mother |
Medical Attendant's Name | P. Joor | Maxwell Ia | Medical Attendant's Address |
Certificate Signer's Name | P. Joor | Maxwell IA | Certificate Signer's Address |
Returned by Name | P. Joor | | |