This is a birth record listed in Siskiyou County.
To request a birth certificate which should have the information you are looking for send $12.00 to
Siskiyou County Recorder
P.O. Box 8
Yreka, CA 96097
Include Full birth name, Date of birth, Entry #, Book # and page #. Also tell them the reason you need the certificate (I'm a fan of "replacement copy"). Entry # is 1963051600004 Book # 29 Page # 388. Hope this helps.