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State Board of Health
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Registrar’s Record of Births
County of

State of Mississippi
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Born In
Voting Precinct, or Village
Registrar’s Register No.. Jf ^—^7______________________
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(Hospital)
or City
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Date of Birth.
Full Name of Child
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Sex, V[ ‘■fr
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.Color.
Full Name of Father
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Mother’s Full Malden Name
Full P. O.? j / i , Address A & O
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Born Alive?.
Name and Addresakr' /? of Attendant s'/tM <"
Date Certif. Filed Date mailed to
_or Stillbom?________________
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State Department	Z'Jp —rf	Ay
or Co. H. Officer it S'.'*	f---
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Address
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Born In
Voting Precinct
or Village, or City_ (Hospital).
Registrar’s Register No-
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Date of Birth.
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Full Nami of Child.
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Sex
Full
.Color
Legitimate?.
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Mother’
Malden Name
Full P. O. a. , ^ Address X / /
Bom Alive?.
Name and Addrq of Attendant.
Date Certif. Filed-
M~ '	19
Date mailed to State Department or Co. H. Officer.
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