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Note: ??? Permanent Record of Births County Roll Number Page Number Ralls C 5618 291 Date of Return (Month/Day/Year) Name of Child Sex No. of Child of this Mother Race or Color Date of Birth Place of Birth 11/16/1884 Leake, Female 2nd White 10/13/1884 Center Twp Nationality of Father Place of Birth Age Nationality of Mother Place of Birth Age Amer Ralls Co. (2)5 Amer Amer 18 Full Name of Mother Maiden Name of Mother Residence of Mother Full Name of Father Occupation Name and Address of Medical Attendant Name and Address of Person making Certificate Returned by Susie E. Leake Susie E. Yancy Center Twp
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