§¥$;195
189 - BERT“ 0F

Child’ 3 Name. Fatlm‘ a and Motficr' aNam . ' . ' ' . 7 . ' . . By whom.
. - > W k - - .V ‘ . r} /
: i

:5N072e%u.%7%6%601 @774 0022.

j J K297W‘Zéw 4% fix»? 1* QM M W
' 9444ma2’4w /404/{ WQM
6W Wfflyu/m.

 

 

/‘

// /! II II

/7r{i~ A 2911627717074 Kit/m ,, 7:
EM“ 9’ W KW, ”
/ 9kg & Qfiwffiwwa %Zaz& ” %
W 0” A47 Kim/{KW ” If
fig; x2 277/ W ~ 5:

‘ a/Ml/ Mam, ’ ‘

x/j Wit/1:66:94 0L ; Clam; V‘KA/é/ M1
/0% 7'Z «L £601ftp WW4

/y/4~j Ila MW @méaw

fin» .20 ‘ /H-’/' fiavzyf my

       

-- f
,. x
- I; ‘