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Registrar’s Record of Births
^	County	of	/w	,
Jtate Board of Health	State	of	Mississippi
Born In
Voting Precinct,
Registrar’s Register No..
Zil
or Village__________
or City (Hospital)
Date of Blrti
Born In
Voting Precinct _ or Village, or City. (Hospital)
Registrar’s Register No-
__________
(K**.
P.M. Date of B
^r1
md£~
if
Pull Name, of Child.
Y}JLT~, P,,J
19 & J7L____________AJbl___________P.M.
Sex.
.Color.
.Legitimate?
Full Name of Father
Sex.	_Color ('~// '_Legitimate ?Q^^_
Full Name ^77//	^
of Father J^k<^±x._____' <- --------------------------
Mother’s Full 7 '// ’	17)	7^	/t7	/
Malden NameX	pcWv i^-C^U^r / ^
Jt /3*
Pull P. O. Address
Born Alive?
Name and Al of Attendai
Date Certif. Filed
Mother’s Full Malden Nami
Pull P. Addres^*.
ti££IU>
Bom Alive?
Name and A of Attendant
Date Certif. Piled
Date mailed to State Department or Co. H. Officer.
RogljtUiirP<~jL™L
Address Ml Ms
Date mailed to State Department or Co. H. Officer
noglatrar
Address.