81443-180368-0596

State File Number: 324

County: Choose County

Child's First Name: Clarame

Child's Middle Name 1: Leroy

Child's Middle Name 2:

Child's Middle Name 3:

Child's Surname: Smith

Child's Suffix:

Sex: Female

Month of Birth (Number): 02

Day of Birth: 01

Year of Birth: 1912

Father's First Name: W

Father's Middle Name 1: H

Father's Middle Name 2:

Father's Surname: Smith

Father's Title or Suffix:

Mother's First Name: Corry

Mother's Middle Name 1:

Mother's Middle Name 2:

Mother's Maiden Name: Haight

Is there an Amendment?: No