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 Time of Birth:  Weight:
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Mother's Information Father's Information
 Maiden Name:  Occupation:
 Occupation:  Parents' Name:
 Parents' Name:  Parents' Address:
 Parents' Address:

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The Cash-Book Journal       P.O.Box 369       210 W. Main        Jackson, MO 63755       Phone: 573-243-3515       Fax: 573-243-3517