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Registrars Record of Births
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State Board of Health
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State of Mississippi
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(Hospital)____
Date of Birth	____________________19^ i^A M_______P.M.
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Full Name ol Child
Sex
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of Father [
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Mother’s Fully Malden-Nam
Full P. Address
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Born Alive?
Name and Adi of Attendant
Date Certif. Filed
Date mailed to State Department or Co. H. Officer.
Registrar
Address
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Born In Voting Precinct
or Village.
Registrar’s Register No-
or City JL (Hospital)___________
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Date of Birth
Full Name O	1	/	S? /•	(]..
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Sex
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F0fU Father	gjft
Mother’s Full ^ ~~7Y	*	s/?/?'	/?	V-/	/?
Malden NameT? ASJ^t^-6Lsijtei ^ic -<fr\
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Full P, Address
Bom Alive?
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Name and Adi of Attendant
Date Certif. Filed Date mailed to
or Stillborn?-
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State Department '//	S’	O
or Co. H. Offliip.r'c	I	7_____
Address ^
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