Child's Name: Violette E. Sampson
Date of Birth: April 19th 1895
Place of Birth: Avon
Sex: F
Color: W
Leg or Illegitimate: Legitimate
Living or Stillborn: Living
No. of children now living: 1
No. of Child, 1st, 2nd, etc.: 2nd
Father's Name: Edgar M. Sampson
Father's Birthplace: Medford Mass
Father's Color: W
Father's Residence: Avon
Father's Occupation: Farmer, age - 53
Mother's Maiden Name: Carrie E Sampson
Mother's Birthplace: Avon Me.
Mother's Color: W
Mother's Occupation: Housework
Name and address of Physician (or other person) reporting said Birth: H. B. Balmer M. D.
