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State Board of Health
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County of
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Horn In
Voting Precinct
Registrar’s Register No._
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or Village________
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Date ol Birth _
Born In
Voting Precinct.
Registrar’s Register No-
or Village___________________________________________________________________
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Full Name of Child.
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Full Name
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gltlmate?
Mother's Full Maiden Name
Full P.
Address
Born Alive?
Name and Address of Attendant *■■
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Date Certif. Filed
Date mailed to State Department . or Co. H. Officer
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Date of Birth.
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Full Name of Father.
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Born Alive?_
Name and AddrelSs-/ , of Attendant ///isist
Date Certif. Filed
Date mailed to / State Department or Co. H. Officer
cy
______or Stillborn?.
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Registrar.
Address.