81443-180362-0649

State File Number: 400

County: Cache

Child's First Name: Stephen

Child's Middle Name 1:

Child's Middle Name 2:

Child's Middle Name 3:

Child's Surname: Smith

Child's Suffix:

Sex: Male

Month of Birth (Number): 8

Day of Birth: 30

Year of Birth: 1912

Father's First Name:

Father's Middle Name 1:

Father's Middle Name 2:

Father's Surname:

Father's Title or Suffix:

Mother's First Name: Irma

Mother's Middle Name 1:

Mother's Middle Name 2:

Mother's Maiden Name: Smith

Is there an Amendment?: No