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OF HEALTH — BUREAU OF VITAL RECORDS / AND HEALTH STATISTICS RICHMOND wae~qas. 7 4- 055: . Tit. COUNTY OF 14 idapendert city, lowe bienh} CME Hishland FV. STREET ADORESS Om BOXTE MO. me cone : 1h, EDUCATION-SPECHFY ; ELEMENT OO TIF HIGHEST GRADE 421208 ‘ 4110 408 So COMAETED ‘ ‘ 4 oF cap {eeve biemkt © Ho) ace OF ° E 7 EOUCATIONSPEGFY | ELEMENTARY =, HIGH SCHOOL 1 60 enathes mat | faTHEa HOGHEST GRADE 191.2708 4 1,2,3084 ¢ 110 408 5 married to tether) : COMPLETED rl ® Pesaran »> (vqnaners of mathe. father, or either oferment) RELATOnoe? Mother Pe ee sonaruer 3} | 28 CTY rau > (eqnctere ot cttmndbeens) ‘ : Ts + } aTremants ON Tr CATE a> HU ] os ond un j CanTeNcaTION ff STATED AtOvE. » Relmel US nag ht _____8,_ 39% aoe ———_ arpeomt: Ganerel Nel: Na 244Qgoe2 tofzz fry os CONFIDENTIAL DATA FOR MEDICAL AND HEALTH USE ONLY | 7B. (5 MOTHER MAARIIED TO FATHER OF CHLDT, ~~ ro“) (OB WAS SHE AT ANY TUAE DURING THE | MONTHS PRECEDING SaTHT) i 8 iy t =U! T. SEROLOGY (OOO = a t ! TEST) PERFORMED } i oO ® ON MATHER oO ww : ie ' rma ta pr ded Ne 4 7 9 macette weecs_| OS SO CNona-_O mmanr__ None. it | 35. COMPLICATIONS RELATEO TO PREGNANCY O8 LABOR @ YES, DESCEME: 34. BATH WN7URES OR CONGENITAL MALFORMATIONS OF CHILD H - IF YES, DESCENE: ; ¢ yar we Oo { 0 Oo el ween — > — aa | ppt oe gee . vos ties