This Certifies that_____________________was born to
______________________ at home, on the___day of
______ 18__.
In Witness Whereof the said Midwife has caused this Certificate to be signed by the duly authorized delivering Midwife, and its Official Seal to be hereunto affixed.

Family History
Father’s Name________________________ Father’s Birthplace______________
Mother’s Name_______________________ Mother’s Birthplace______________
Sex of Child_________________ Number of Siblings_________________
Religious Affiliation_____________

Date

Physician/Midwife Signature

Darke County, Ohio

Birth Cerificate