81443-180368-0683

State File Number: 359

County: Salt Lake

Child's First Name: Agnes

Child's Middle Name 1: Mildred

Child's Middle Name 2:

Child's Middle Name 3:

Child's Surname: Patterson

Child's Suffix:

Sex: Female

Month of Birth (Number): 02

Day of Birth: 04

Year of Birth: 1912

Father's First Name: S

Father's Middle Name 1: T

Father's Middle Name 2:

Father's Surname: Patterson

Father's Title or Suffix: Dr

Mother's First Name: Mabel

Mother's Middle Name 1:

Mother's Middle Name 2:

Mother's Maiden Name: Burnett

Is there an Amendment?: No