DATE OF ; ‘ B APTISM. 'BY WHOM BAPTIZE/p:

1/32 ”M?” Mic/114.1;

CHILD’S NAME. r’N'A‘ME: OF PAfiENTs.‘ ' DATE OF

BIRTH. /% / \ .1 , WM» zme

| ‘1 /y i ‘ _ fl j .‘1 IVE/fl

7——