Child's Name: [blank]
Date of Birth: May 1, 1902
Place of Birth: Claremont
Sex: F; Color: W.
Living or Stillborn: Living
No. of Child: 3rd
Father: Chas. A. Rice
Birthplace: Webster, N.H.
Color: W; Age: 35
Residence: Claremont
Occupation: Steam-fitter
Mother: Grace Shaw
Birthplace: Salsbury N.H.
Color: W; Age: [in pencil: "34", appears off by 10 years]
Occupation: House wife
Clerk of: Claremont N.H.