Birth ID:                    

Certificate Location:        
Certificate Number:          

Birth Location:              
Birth Date:                  

Name:                        
Immigrant ID:                
Sex:                         

Parents' Home Address:       



Father's Name:               
Immigrant ID:                WIEL-26SEP1890-3--0383 CELT-18OCT1909-2-8-0029 
Birth Place:                 
Occupation:                  

Mother's Name:               
Immigrant ID:                CELT-18OCT1909-2-8-0030 
Birth Place:                 
Occupation:                  

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

Parents' Marriage Date:      
Parents' Marriage Place:     


Comments:
                             filed in Book D, p. 175