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Registrar’s Record of Births
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State Board of Health
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State of Mississippi
Born In
Voting: Precinct-
Registrar’s Register No._
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or Village.
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(Hospital).
Date o( Birth
Pull Name of Child
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Sex	^	Color	Legitimate
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Full Name /? of Father
Mother’s Full Maiden Namg2^£^±4.
Full P, Address
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Born Alive?.
Name and Addr of Attendant
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_or Stillborn?.
Date Certif. Filed. jfaf A/isCs/i.—J} f
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Date mailed to	^,	.
State Department \J)S _
or Co. H. Officer.
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Registrar
Address.
Born In
Voting Precinct.
Registrar’s Register No.
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or Village, or Cltyj^ (Hospital)_________
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Date of Birth	.	19£J	_
Full Name of Childc.
Sex
Full Name of Father
Mother’s Full CL	sLS //
Malden Name	7/	&■
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Full P, Address
Bom Alive?.
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.or Stillborn?.
Name and Ad of Attendant
Date Certif. Filed
Date mailed to State Department or Co. H. Officer
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