81443-180368-0640

State File Number: 341-a

County: Salt Lake

Child's First Name: Irene

Child's Middle Name 1: Elaine

Child's Middle Name 2:

Child's Middle Name 3:

Child's Surname: Jacketta

Child's Suffix:

Sex: Female

Month of Birth (Number): 02

Day of Birth: 02

Year of Birth: 1912

Father's First Name: Ralph

Father's Middle Name 1: Raphael

Father's Middle Name 2:

Father's Surname: Jacketta

Father's Title or Suffix:

Mother's First Name: Dora

Mother's Middle Name 1: Teresa

Mother's Middle Name 2: Franco

Mother's Maiden Name: Carta

Is there an Amendment?: No