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State Board of Health\ £
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Registrar’s Record of Births /L County of

State of Mississippi
Born In
Voting Precinct _ or Village.
Registrar’s Register No._
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or City
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(Hospital)
Date of Birth /ffasttM. .1 IT.__19&? (x
P.M.
Full Nami of Child1
Date mailed to State Department or Co. H. Officer
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Address
Born In
Voting Precinct, or Village, or City, (Hospital)
Registrar’s Register No.
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Date of Birth
Full Name of Chlld_
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Sex yTA—	nnlnr / (J_Legitimate? ,y-~?5—
Mother’s Pull Maiden Nami
Full P Address
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Bom Alive?
Name and Addri of Attendant
Date Certif. Filed
Date mailed to Btate or Co,
Registrar
Address.
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