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Newborn baby's name:
Date of Birth:
Place of birth, including address:
Is the baby male or female?
Mother and father's first and last names, including mother's maiden name:
Mother and father's home address, including city:
Additional Family Information
Names and ages of siblings:
Grandparents' first and last names and addresses, including city:
Great-grandparents' first and last names and addresses, including city:
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