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Kegistrar's Kecord ol liirtns
County of
State Board of Health
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State of Mississippi
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Born In
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Registrar’s Register No.. /-/ ____________________________
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Date of Birth.
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Full P,
Address
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Name and Address// ~~C of Attendant	<
Date Certif. Filed
Date mailed to State Department or Co. H. Officer
Registrar.
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