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State Board of Health
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Registrar’s Record of Births
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Voting Precinct
or Village or City (Hospital) _
Registrar’s Register No,
Date of Birth.
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P.M.
FuU Name of Child^
Sex
Full Name of Father.
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Color.
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Full P. O. Address
Born Alive?____/y
Name
_or Stillborn?
fame and Address' XK, /	1	/Sy
of Attendant___C^/t&r&tSA.—
Date Certif. Filed.
Date mailed to Btato Department
or Oo. 11. Ofdoei'
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State of Mississippi
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Bora In
Voting Precinct 'pT <
or Village_____________
or City-JqL (Hospital)
Date of B;
FuU Name of Child_
Registrar’s Register No_
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Sex
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Color_
Full Name of Father
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Mother’s Full /P Maiden Name/( ^<LQ.
Full P.
Address
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Legitimate?
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Born Alive?.
Name and Addri of Attendant
Date Certif. FUed.
Date mailed to State Department or (Jo. 11. Ofllwr
Registrar fX-r '7 Address_______________
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