Birth ID:                    

Certificate Location:        
Certificate Number:          

Birth Location:              
Birth Date:                  

Name:                        
Immigrant ID:                
Sex:                         

Parents' Home Address:       

Father's Name:               
Immigrant ID:                NYRK-26DEC1896-2--0037 ETRU-17JUL1904-2-B-0021 
Birth Place:                 
Occupation:                  

Mother's Name:               
Immigrant ID:                ETRU-17JUL1904-2-B-0022 
Birth Place:                 
Occupation:                  

No. of Children Born:        
No. of Children Now Living:  

Parents' Marriage Date:      
Parents' Marriage Place:     


Comments:
                             filed in Book B, p. 109