| What were my birth parents' names? |
| Mother: |
| Father: |
| Were my birth parents married to each other? |
| Where were they from? |
| Did they have family in the area? |
| Other family background: |
| Physical description: nationality and race |
| Mother: |
| Father: |
| Education |
| Father: |
| Mother: |
| Occupation |
| Father: |
| Mother: |
| Ages |
| Father: |
| Mother: |
| Religious affiliations |
| Father: |
| Mother: |
| Other Relatives: |
| Medical information |
| Father: |
| Mother: |
| Reason
for relinquishing child
|
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