81443-188585_745

State File Number REQUIRED: 2032

County REQUIRED: Salt Lake

Child's First Name:

Child's Middle Name 1:

Child's Middle Name 2:

Child's Middle Name 3:

Child's Surname:

Child's Suffix:

Sex: Male

Month of Birth (Number): 6

Day of Birth: 28

Year of Birth: 1914

Father's First Name: Leni

Father's Middle Name 1: W

Father's Middle Name 2:

Father's Surname: Thompson

Father's Title or Suffix:

Mother's First Name: Stella

Mother's Middle Name 1: M

Mother's Middle Name 2:

Mother's Maiden Name: Hancock

Is there an Amendment? REQUIRED: Yes

Document Type REQUIRED: Certificate