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Registrar’s Record of Births	^	»
County of	f ik
State Board of Health	State	of	Mississippi
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Bom In
Voting Precinct .
Registrar’s Register No. /
_____________________
Full Name of Father.
Mother’s Full Malden Name
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Full P, Address
Born Alive?
Name and Address of Attendant
Date mailed to State Department or Co. H. Officer
Bora In
Voting Precinct.
or Village________
or City (f%<X (Hospital)
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Date of Birth.
Full Name	ri/I [j	/	/>	^
of Child	  -S /^-i—1 J1—
Sex.
Full Name -£J	/	/£
Of Father(r?<gT^~tCY'<gyl (£)a
Legitimate ? JMsd ...
Mother’s Full Maiden Name
s JJSVUsTJc.
Full P. O. Address // Q
Bom Alive?.
Name and Adi of Attendant
or Stillborn?.
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Date Certif. Filed.
Date mailed to State Department or Co. H. Officer.
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Registrar.
Addinon
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