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State Board of Heajt
^S^^egistrar’s Record of Births , Jg?' County^#^7^
State of Mississippi
Born In
Voting Precinct
Registrar’s Register No._ yjrffor sft___________________________
or Village__________
or City JQ
Born In
Voting Precinct.
Registrar’s Register No_
-----------
(Hospital)
Date of Birth_
TST C^,.%JL»%
Sex
Full Name
______Color _ . 9f _Legitl
fL_, hm-— /yt	A
of Father ( . ['
Mother’s Full Maiden Name
Legitimate? V JU? ,*Ld^>
Full P. Address
or Village_________
or City /§ (Hospital)
Date of Birth
Full Name of Child.
Sex
Full Name of Father.
Born Allve?_
_or S til loom?
Name and AddrW^	~£ //	'	/	S?	Cl
of Attendant '7'^^ i	yb.{*
,n
Date Certif. Filed Ht-
Date mailed to	f/
State Department
\^y>
19 ftZ.
or Co. H. Officer-
.19-
Address
'■f. a
<n-
Mother’s Full Maiden Name
Full P. O. Address
Bom Alive?
-yU.y&L
Name and Addri of Attendant
Date Certif. Filed
Date mailed to /, State Department or Co. H. Officer
.19-
Uoglflti'ar.
Address.
JlL.
9 ■//
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