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State Board of Health
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Registrar’s Record of Births
County of
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Voting Precinct.
Registrar’s Register No._
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Date of Birth
Full Name of Child
Sex
Full Name of Father
Mother’s Malden Ni
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Born In
Voting Precinct.
Registrar’s Register No_
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Date of Birth.
Full Name of Child.
Sex.
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Full Name of Father______v_
Mother’s Full Malden Naitie
Full P. Address
Born Alive?
Name and Addri of Attendant
Date Certif. Filed
Date mailed to State Departmenl or Co. H. Oft
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Address
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