| Reg. Dist. No. |
3101 |
| Registrar's No. |
63-12811 |
| Birth No. |
134-63-128402 |
| Place of Birth: County |
Hamilton |
| City |
Cincinnati |
| Name of Hospital |
Bethesda Hospital |
| Inside City Limits? |
Yes |
| Usual Residence of Mother: State |
Ohio |
| County |
Hamilton |
| City |
Cincinnati 66 |
| Street Address |
848 Glenwood Avenue (29) |
| Inside City Limits? |
Yes |
| On a Farm? |
No |
| Child: Name |
Karin Elizabeth Gottlieb |
| Sex |
Female |
| This Birth |
Single |
| Date of Birth |
August 28, 1963 |
| Father: Name |
Anthony Adams Gottlieb |
| Color or Race |
White |
| Age |
27 years |
| Birthplace |
Missouri |
| Usual Occupation |
Physician |
| Kind of Business or Industry |
Cincinnati General Hospital |
| Mother: Name |
Priscilla Ann Wendt |
| Color or Race |
White |
| Age |
26 years |
| Birthplace |
Wisconsin |
| Previous Deliveries to Mother |
0 |
| Informant's Name |
Mrs. Priscilla Ann Gottlieb (Mother) |
| Mother's Mailing Address |
848 Glenwood Avenue, Cincinnati 29, 0. |
| Date Serologic Test for Syphilis |
4-22-63 |
| Signature |
Stephen Gornstein M.D. |
| Address |
7719 Reading Road (37) |
| Date Signed |
8-28-63 |
| Date Recd. by Local Reg. |
Sep 9 1963 |
| Registrar's Signature |
Mary Ann Berens |
