W 2”, \ f ’1“
M 41/“ M, W/“/% Wflpu ’7‘”. ‘

'-
‘ i ‘ _ v A ,’\, ' " ’1‘28 9
I 41.9,; 490.». 11», r 9/ J74 » ,, -

| CHILIS’S NAME. 'NAME OF PARENTS. 1 DATE OF‘
5 ,

 

BIRTH.