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Child's Name:	(Lastname, Firstname)
Certificate #:
Date of Birth From:		To:	(mm/dd/yyyy)
Date Filed From:		To:	(mm/dd/yyyy)
Mother's Name:	(Lastname, Firstname)
Father's Name:	(Lastname, Firstname)

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Internet Public Access Module Version 3.1 Copyright 2001, 2002 Manatron, Inc. All Rights Reserved.