81443-180360-0346

State File Number: 143

County: Beaver

Child's First Name:

Child's Middle Name 1:

Child's Middle Name 2:

Child's Middle Name 3:

Child's Surname: Booth

Child's Suffix:

Sex: Male

Month of Birth (Number): 9

Day of Birth: 1

Year of Birth: 1912

Father's First Name: Elias

Father's Middle Name 1: J

Father's Middle Name 2:

Father's Surname: Booth

Father's Title or Suffix:

Mother's First Name: Julia

Mother's Middle Name 1: Leana

Mother's Middle Name 2:

Mother's Maiden Name: Law

Is there an Amendment?: No