. DEPARTMENT OF HEALTH OF THE CITY OF CHICAGO Swiss . ..L."REA" OF VITAL STATISTICS

CERTIFICATE AND RECORD OF BIRTH

3. Sex of n?. I 4. Tavzhtp& Number in order 5. Date of PIAlA of birth ______________, ---1..---- (To be answered only & event of plural births)

6. FUL NAll kmth) (Day) (Year)

8. COLOR 9. AC&T 1 14. COLOR

10. BIRTHPLACE 16. BIRTHPLACE 11. OCCUPA . * a/ ' 17. OCCUPATION I /A / ___-

/ 18. Numberofcbiljrenbornto tbiamother,includias present birth-.--- -_ /.I -7 19. Number of children of tbis mother now living-.. --.-__--_.___ ~.__ ___- ~-~--~ ~~~ \ 20. CERTIFICATE OF ATTENDING PHYSICIAN OR MIDWIFE.*

1 hereby certify that I attended the birth of this cbii. w d- o a* born alive at/--1b---t-IJ-- _-~-I'& on tbe date abc

i . l When there WM no attending physician or _ mldwde. then the father. mother. householder. ) _ , .adi Adl~~ket"is return. See sec. 12 of \

22. Give name added from a supplemental

_- _______________________ _ ________ -__ Registrar

STATE OF ILLINOIS, COUNTY OF COOK. CITY OF CHICAGO

I, M. 0. HECKARD, M. D., Registrar of Vital Statistics of the City of Chicago, do hereby certify that the foregoing is a true copy of the records kept by me, in pursuance of the laws of the State of Illinois and the ordinances of said city.

.:.-es .> 1 SEAL 1 .:a--- .:. - e' In witness whereof, I have hereunto set my hand and the seal of the

DEPARTMENT OF HEALTH, -- 19-

M. D. Registrar of Vital Statistics.

Form H.D.V. 133A 10M l-16 -970

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