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aay pam She ICnenO CEERI OE sa quer 1; PLACE OF BIRT ta) City of Town.’ (e} Name ot Hospi “San Rafael Cottage Hospital =" 4 ls) City or Town SBM. Rafaed . at wOd aM WOWITAL OF INST Ulm, Orv sTtEat WUMSER OF LOCATION + TF OuUMIOR CATT O8 TOWN Limits, wel {0} Mother't stay’ eat to pert .. es Be (0) In Hospital ar Institution, In this conimunity_—_¥ G8... >» {t): Street and Number. * g SPRCUPT WEIMESD TEARS. MOKTHS Of GATS, ab Number of Month t Preijnency.1. fGen oy - bef’ mOntn BT NAT we Pet ys ay” MOTHER OF CHILD I$, FULL MAIDEN ~_ NAME. 1é, TOLOR on RACE * Statz or CaLirornia } | _ 3 : County Cr Manin bss. i 7s 1, N. T, Giacomini, County Recorder in and for said County and State, hereby certify that the above and foregoing . as hereunto annexed, is a full, true and correct copy of an Instrument of Record in my office, as the same appears recorded ER. , 3 ——aa Af . | in Liber needed savesensennseens ek | teteadereeeeeee Births seuseneesanen seeeeseeeseoeereneesanrensenenesaces senaeoeeees PHBE weal " a. E * ot Marin County Records, and that the copy has been compared by me with the original, and ia a correct transcript there- 7 OS 3 ‘ + — from and of the whole of said origina! record. —~ Oe F. 5 sme ke 18th December ro " Seal Chik. eee cecrceserrceareeeccees GRY Of. ee wteitererereeneseasesecemed, Dh, 1974 J. tadler “Deputy Recorder . aa Bin wok > ie pT, : -”* eae, Ce eee ee et Gore