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Registrar’s Record of Births
County of
State Board of Health
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Registrar’s Register No..
Date of Blrthc
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Born Alive?.
Name and Adi of Attendant
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Date Certif. Filed.
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State Department ~f f q or Co. H. Officer {7*#'—
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Mother’s Full Maiden Name
FuU P. Address
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Name and Addr^ of Attendant
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Date Certif. Filed.
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