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Registrar’s Record of Births^
State Board of Healtti „
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County of
State of Mississippi
Registrar’s Register No._
Born In
JJ.A
Date of Birth
Full Name ol Child
fi	w&J
Sex
Full Name of Father
Sec.
.P.M.
Color uf Legitimate ? ‘r~^~
Mother’s Full Maiden Name.
Full P. O. Address.
Born Alive?.
Name and Address of Attendant
Date Certif. Filed
Date mailed to State Department or Co. H. Officer
_or Stillborn?.
Registrar. Address.
Born In
Voting Precinct, or Village. or City. (Hospital)__________
Registrar’s Register No.________/	3
JLT~
Date of Birth
Full Name of Child.
ZT 19 A? __________________A.M. S*'P M.
Sex
UtUld.
. Color	Legitimate
Full Name of Father.
Mother’s Full Maiden Nai
FuU P. O.
Address
Born Alive?.
Name and Addrj of Attendant
Date Certif. Filed
Date mailed to State Departin' or Co. H. Officer
Registrar.
Address