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SpouseName: 
     
Husband Name: 
     
Date of Birth: 
     
Place of Birth: 
     
Date: 
      
File No: 
      
Method of Birth: 
      
Age of Baby (weeks): 
      
     
The Baby is:
   Male Female
Was there effects after birth:
   Yes No
Needed an intense care:
   Yes No
 
Other information: 
  
        
   
     

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