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^	^	Registrar’s Record of Births* ' ‘a
' h	County	of	'
State Board of Health	State	of	Mississippi
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Reglstrar’s Register No.	ft'
or Village_______
or City_y^,
(Hospital)
Date oI Birth (J/Zsp*/ /<r_______lQjf/- // A Jul.
Full Name of Child.
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sex
Full Name of Father
.Color.
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.Legitimate?
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Mother’s Full Malden Nami
Full P. O. a / Address cl //<J
Born Alive?
Name and Addri of Attendant
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Date Certif. Filed
Date mailed to State Department or Co. H. Officer!
Registrar
Address
Bom In
Voting Precinct*
Registrar’s Register No_
inct
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or Village, or City (Hospital)
Date of Birth
Full Name of Chlld__
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Sex.
.Color.
9r-
Legitimate
Full Name of Father.
Mother’s Full Maiden Nami
Full P. O Address
Bom Alive?
Name and Adi of Attendant „
S'
Date Certif. Filed.
Address.
Date mailed to State Department or Co. H. Officer
Registrar