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i <br /> For the Year 19 Yo- <br /> OCCUPATION <br /> OF <br /> FULL NAME OF FATHER MAIDEN NAME OF MOTHER FATHER BIRTHPLACE OF BIRTHPLACE OF DATE CF *' <br /> OCCUPATION OF FATHER MOTHER RECORD <br /> MOTHER <br /> f <br /> &7- <br /> �. <br /> I . <br /> - - - - - A 5' 191X(11?A917 LA <br /> -- : <br /> - 90 «fr <br /> I <br /> S <br /> 11 � <br />