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State Board of Health
xvegisirars Keeord of Births
County of
State of Mississippi
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Born In
Voting Precinct
Registrar’s Register No._
IX1
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or Village________
or City fi (Hospital)__________
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Date of Birth	/ .lislS'-JL--A
Pull Name ti (J / J t' I If /? of Child JiCL^CA^f^U	r<?
M.
.P.M.
Sex.
Full Name of Father.
.Legitimate?
Mother’s Full Maiden Name
Full P. O. .'1 Address______/Y7^W ,-ZY
Bom Alive?
Name and Addri of Attendant
Date Certif. Filed
Date mailed to State Department or Co. H. Officer
/ /)	y	,
Registrar. rL/ 'I	L^\
Address
Born In
Voting Precinct, or Village, or City. (Hospital)__________
Registrar’s Register No.
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/?
Date of Birth ujyQ/^7‘2^xy'C~ct S' ig 3 ^
Full Name of Child ^
Sex
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.Color.
Full Name	I	ts	-~f	7^
of Father CfO^^/'y.-L'-i- L ^	d
Mother’s Full	^	/	/	~r~	(IV	/
Malden Name /A	^	<=t
(>L
’T*
Full P. O. Address _
£
Bom Alive?.
Name and Address^ / of Attendant
Date Certif. Filed_ji
Date mailed to State Department or Co. H. Officer
Registrar.
Address