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nj_ Registrar’s Record of Births	•<
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State Board of Health	State of Mississippi
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Voting Prer.inr.t fyf
or Village_________
or Cltv ¥& (Hospital)__________
Registrar's Register No._
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Date of Birth _
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Name (zjtp	/ -~yt //a
Child________AL	KO
Pull Name of
Sex.
.Color.
Legitimate
Full Name of Father.
Mother’s Full Maiden Name,
Full P. O. o. g Address (
Born Alive?
Name and Addri of Attendant
Date Certif. Filed
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Date mailed to State Department or Co. H. Officer
Registrar Address -/J-
Born In
Voting Precinct, or Village.
Registrar’s Register No_
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or City. (Hospital) _
Date of Birth
Full Name of Child
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Sex	Color.	-	Legitimate?___
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Full Name of Father.
Mother’s Full Maiden Nami
Full P. O. , Address c____> I (
Bom Alive?
Name and Addri of Attendant
Date Certif. Filed.
Date mailed to State Department or Co. H. Officer
Registrar Address M
or Stillborn?
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