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Registrar’s Record of Births
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State Board of Health ^
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County of
Born In
Voting Precinct. or Village.
Registrar’s Register No..
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Date of Birth
Full Name of Child
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Sex
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Full Name of Father
Mother’s Full Malden Nam
Full P. O. Address
Born Alive?
Name and AddresC/JO ~p^~ of Attendant i/ri/^0 CP '
Date Certif. Filed.
Date mailed to State Department or Co. H. Officer.
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Address
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State of Mississippi
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 ^Crtstsf-
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Full Name of Father(c?
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Legitimate?.
Mother’s Full /?	()	)r	’	/Q	1
Malden Name^'L-^'^	/r)	7.	cj
Full P. Address
Date mailed to State Department or Co. H. Officer
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Address_________________________________________________________________________