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State Board of HealtJ
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Registrars Record of Births
County of fj
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Born In
Voting Preclnc
Registrar’s Register No..
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or Village___________
or City. J£>
(Hospital).
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Date ol Birth,,
ry t &
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M.
Sex tyl/CaJLeZ—_______ _ Color.	. Legitimate ?
Pull Name ////?	/?	/')	^a_ Cl*
Pull Name of Father
Born Alive?
Mother's Full Si j /, Maiden Namei	f
Full P, Address
Name and Addreas^/^ '	/	sy
Of Attendant (/O/S^
Date Certif. Filed Date mailed to
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State Department 77	/	^
or 00, II. Offlooi* ,.	/J)
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is 93 A$Z
Registrar,
Address
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Born In
Voting Precinct
or Village or City. (Hospital)
Registrar’s Register No. 'T-da^c
Date of Birth 1'trr / ?
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Full Name of Child <■V (X**Sl 4
P.M.
Sex.
Full Name of Fathe:
Mother’s Full Malden Name
_ Color. or . Legitimate ?
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Full P. o. Address _
Bom Alive?.
_or Stillborn?.
Name and Address^ of Attendant O?
Date Certif. Filed.
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Date mailed to State Department or Oo. II, Offloflr
Registrar.
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w/r'‘2>
Address.