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Registrar’s Record of Births
County of
State Board of Health
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State of Mississippi
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Born In
Voting Precinct
or Village
(Hospital).
Registrar’s Register No._
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Date of Birth
Full Name of Childz^
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Sex -
_ Color.
Full Name of Father J_
Mother's Pull J,	Vr ‘	//
Malden Nam^,	/i	r * <
Full P Address
Born Allve?_
_or Stillborn?
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Name and Address/ / of Attendant p!/
Date Certif. Filed
Date mailed to State Department or Co. H. Officer.
Registrar
Address
Born In
Voting Precinct, or Village.
Registrar’s Register No.
or City. J2l (Hospital)	s£
Date of Birth	°(	'	19	3f	(n	AM______P.M.
Full Name (// /'/' <	/ /	"Z'	/
of chiw/ss/'/^e r\f H't'ULu/
Sex.
.Uuu.
T .Color
Legitimate?.
Full Name £/" of Father,^-i/
Mother’s Ful/	/	/,	/ .
Malden Namiy ; //-C'-C-f fotc?'*!
V //ui.
Full P. O.
Address	<.
Bom Alive?.
.or Stillborn?.
Name and Address / / ■	i	/'
of Attendant -> -r/. ; . -A t _________f-' iA C. *'*"
Date Certif. Filed_
Date mailed to
State Department	"TVy
or Co. H. Officer
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_19_,2y_y ■ 19-i-^r
Registrar.
Address.
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