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State Board of Health ^
Registrar’s Record of Births
X 3	County of
State of Mississippi
J - - /l
<IAX l&Slsi/W	1	 Registrar’s Register No. Bom In .	... _ .. _ .\*fT3'L-M ^ .3 ✓V*' U ’ / r~ Registrar’s Register No. CO 6m (. Bom In // Voting Precinct
or Village	or Village
or City /§)<*-%-/ J	or City /^‘i^--/
(Hospital)	^ (Hospital) ‘ s{'/( .{// ^	
p„t® nf Wrt.h 719 A 7 A.M. //'"p.M.	Date of Birth /> mJ / 7J am pm
Full Name J? / i (\y fit' '13/7 nt Hhilri (^yy-tx^x C.L V-/Cy.^^. (/p-	Full Name() 1 / S Of Child /;/' /lX^Lc^ivI six O. I -' ^tr~r t -
rat Color Q't'tu'Cc' Legitimate?	
^ Father	Full Name /I $ s,~ /f ^ of Father
Mother’s PuU (1. —^ C? / ' Malden Name '’V^ W ,-t. L <s t-^L.	Mother’s .Full fa . ~/-~ ,y ( —< /> {/".... Maiden Namec*-c <> . ft?..* *✓» f? *^v_
,IC r/^uSc^	Fuii p. o. /-.; / < >- ' // ■; ,, r ~ / Address /&Sl-Cs. -r j£C .-n v.- /
Bnrn Alive? _ or Stillborn?	N Bom Alive? ' nr St.tllhnm?
Name and Address), i/*" :/ /'' nf Attendant /yi'\s> (y? st*AsC—<MA't •	Name and Address/ j! . of Attendant r'-.T-t.-i '.*9
natfi fiertif. Piled ■ ^ 19.1_?	Data fifirtJf. mi*ri 10,1 J
Date mailed to State Department ^ nr r.n H Offlnpr lfl.£ 7	Date mailed to State Department nr r.n W Offl^r ' 19.1 ’
lU^litrir /(/f I , ■({? . ..	Ss .--Ji /-• 	_ Uoulalru* ..v <. > ' i . •/*• J L**'
A^rlr»cs jfc) /£'(	AririrpKS /<■'-/ ^ —7