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State Board of Health
Registrar’s Record of Births
County of
State of Mississippi
Registrar’s Register No,
Bom In
Voting Precinct or Village	-irr-		
or City	/*		“V.
(Hospital).
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Born In
Voting Precinct.
Registrar’s Register No-
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or Village_____
or City— (Hospital)___________
El
x.
-
Date of Birth
Pull Name of Child-
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Sex.
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Color J
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Legitimate
Pull Name -£	'	/	y
of Father '"LP QIajL.	.ft	(2
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Mother’s Full i/ u Malden Name Ki' L, ia
Full P. O.
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Full P. O. a. ^ ,1 Address a c a JS Af-Ti.
		
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Born Alive?.
Name and Address of Attendant________
ki
id.__________Qz.
or Stillborn?_________
Date Certif. Filed Date mailed to
State Department (Li /	S	<f
or Co. H. nffinftr sit	<*	y	™-Yf)
Registrar /<f ? (f ^*•—_____________________________________________________
Addrtuts	' j
Date of Birth '£
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Full Name of Chllrl-^	U-	0
Sex±_
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Full Name of Father.
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Mother’s Full Maiden Name.
Full P. o. Address
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Born Alive?.
Name and Address 0,1	~J-
of Attendant	_i.'
.or Stillborn?,
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Date Certif. Filed.
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Date mailed to	(y
State Department	/ ./	/	°]	!j	-
or Co. H. nffWr >. /	A	<*■	I
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Reglstrar y.J- - ■
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