CE~TIFICA_TE - OF BIRrrH. · ·:. ·;(T~'¥:i'Ciutn~:it:~t~30Aaf,Stti :lbtHc.lth Olfr.er or if 1I0ne totheClerlt~f the tow1l,viUagt,(Jt . City ' in .

. . . " · w$ch·theBlrth,dGCutli;andbyhlm to the Register of Deeds of his CountY.) .

••• • ,,' . ".

8 •. Sex

4 . . ~me of otherLliVing (born of saIDe PBrents,/;~?--~ »~~ ? / CL-/ff~~d' ~ ._ ...,..--. J v: ./

6. Full nBme of father c<- ~ ~ 'ie? ~ Z--<.2-~ 6. Occupation of father ~~. L..------c::; . 7. Full nBme of mother previous to marriage ~--z--z.-=-z...-e:(.

8. Hour, day of week, of month, and year of birth..:f7 r(:j t::::' a.... ~ .. / . ~~ H _ _ _ __ _ • ~.£-Z; /~ - /Ze ~ t/'

~:r->'4 ' ;7 O . . The place (b), town or township Rnd county in which born~ /~~~

v~~.~~~ .. g-,

10. Birthplace of father k/ ~----------------------------------.----------

n. Birthplace of mother ___ --=:.~ __ -=_'_~ ___________________________________ __

12. Any <:lther important informa.tioll __________ ________________ _

Residellced /,7 - c7

..... . ::..:....: \. .: .: . . Dated a1>-t _______ -.,-__ saicl County, t,hi~ }

DC'" ',il" 1!'Wi ________ Iday of ' I ' . , ~ 11)0 .

F. M. SCH.ULZ.

(c) Health O(Heer. "rintft 8P cur Clerk

N GTE_-( a) Stat.e the color so' distinctly that the race nlso may be understood, RS White, Black, Mulatto, Indian, Mixed White nlld Indian, etc. (11) If citt , ill"ert . t,reet and !lumber. (c) Strike ant the worlls not representing the olie sigllingthe return . State nily import,ant facts ill making the return-lion illegitimate birth, or still birth should be 80 specified '

- --'. - ---- ".- - -.. :-:: / ----­

Recorded tbelL---='--==-~_'" ,.:./_. __ -.:.. day Of ___ ...cl::=J::::.·· _· .. -' ... '-::._-.==~~_· ::_- _. -:-:--A. D. 190 , · . .

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-'-_____________________ ~ _________ .'_= .. Relli~ter~ . -. .. _---.-

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.' . _ -.. 7' - "" '7';7"7:; 1"--"'-- (b), town or ttiwhship and county in which l}ornV' , .......-- ?:= ~ ; ,', . , •• ,, ".:. ": : ;;. " __ m ___ _ ____ • • •• -~~~~-;dt--L--?~~:-:----'--~- _._ . ____ _

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" .. : J~. ' ·' ~J1.Y(Jther important informatioll ___________ ~------____,_-------" " ' , " " : '

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·..,..,, -:- ··-··· .. · · · ··"-f~·-':";; -.-

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(C) PhysIcIan, MM "lEe 8. 8""" ~e'BBA I'Bllortlng . 1 i .

c:i1~ '7 _/~ //7 1/ . Ir -~~-~ --ce ~-~. -~~~-~ --(.,..~ I: . " .'

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