Birth ID:                    

Certificate Location:        
Certificate Number:          

Birth Location:              
Birth Date:                  

Name:                        
Immigrant ID:                
Sex:                         

Parents' Home Address:       

Father's Name:               
Immigrant ID:                INMR-10NOV1917-3-3-0002 
Birth Place:                 
Occupation:                  

Mother's Name:               
Immigrant ID:                PEMR-04JAN1918-3-11-0003 
Birth Place:                 
Occupation:                  

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

Parents' Marriage Date:      
Parents' Marriage Place:     


Comments:
                             filed in Book 2, p. 489