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BIRTH PARENT COMPLETING THIS FORM IS THE BIRTH MOTHER SECTION I INFORMATION ABOUT BIRTH PARENT AND CHILD PLACED FOR ADOPTION Name CHILD Last First Middle Birthdate mm/dd/yyyy Child born at home Name Midwife if attending Child born in hospital Name Attending Physician Birthplace City State Name Current BIRTH MOTHER Last First Middle Name Hospital Name Maiden Last Address Permanent Street City State Zip Code Telephone Number Name BIRTH FATHER Last First Middle Yes No Are the birth parents ...

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