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. STATE OF CALIFORNIA a DEPARTMENT OF PUBLIC HEALTH . 1, PLACE OF BIRTH. Ole He -ClOL VITAL STATISTICS Leal Kegiasenat 23,, BO COUNTY OF MARIN: STANDARD CERTIFICATE OF BIRTH CITY or . ‘AURAL REGISTHATION DISTAICT.___SAN RAF. wereinescnntcpeamns os oon NODaE LOotens Place g._ . birth occurred in a heapita] or institution, give ita NAME instead of sires ETf child is oot yet named, make 2. FULL NAME OF CHIL... _Vionr sOnpleinentai repart as dimeund | 4. Twin, triplet, of other. 5. Number, In ordor of birth FATHER Hfplural { births } MOTHER < . malden namé........, Lou Shoe a me enter + tone ee Saaee 914 Lootens flaca” - 914 Lootens 9. Residence (uaua! place of abad i t, sa 18, Residence (ususl place of abode: ~ ¢- ' if noureeident, give place and State} eee man safae i, Celife it nonresident. give place sig State). PAR Bat 19. Color or rate Chine a¢ ol. Biethplace, 2 ¢. x}. Trade, profemion or particular kind of work done. os housekeeper, i, COUNTY CP Many } . i is ad in and for said County: . a freuato annexed, is a full, true and correct copy of an In unky rave Sin ey aal?, athe above “and foracing .. ae , st a “me appears recorded. PA 13. Trade. profension, of particular tr Dd, 19 75 ove stated. N..T. GIACOMINi . Set by 1 Lt hater ras t sat : * tar Pop sar Re Kaen = 5 oe 4 ay en