81443-180361-0577

State File Number: 553

County: Box Elder

Child's First Name: John

Child's Middle Name 1: Dean

Child's Middle Name 2:

Child's Middle Name 3:

Child's Surname: Potter

Child's Suffix:

Sex: Male

Month of Birth (Number): 12

Day of Birth: 2

Year of Birth: 1912

Father's First Name: William

Father's Middle Name 1: Ernest

Father's Middle Name 2:

Father's Surname: Potter

Father's Title or Suffix:

Mother's First Name: Olive

Mother's Middle Name 1: L

Mother's Middle Name 2:

Mother's Maiden Name: Moon

Is there an Amendment?: No