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/^Registrar’s Record of Birtip, q ^ &<Jr County of
Mississippi
a
State Board of Health
State of Missis
Bom In
Voting Precinc
Registrar’s Register No..
Born In
Voting Precinct.
Registrar’s Register No.
or Village
or City -/Sj (Hospital)
j2zl
a^ui^o
Date of Birth.
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-KM..
.P.M. Date of Birth
Pull Name of Chili.
c/
.PM.
Sex
_ Color .
.Legitimate?.
Full Name of Father,
Mother’s Full Maiden Name
Full P. Address.
Born Alive?
Name and Ad of Attendan
Sex_
Full Name of Father.
.Color
Mother's Full Malden Nam^
or Stillborn?.
Date Certif. Filed
Date mailed to State Department; or Co. H. Officer.
IlftyUU'Ai
Address -
Bom Alive?.
0	19
Name and Adi of Attendant
_or Stillborn?.
Date Certif. Filed
3-0._______wi^
Date mailed to State Department or Co. H. OfficerJ!
Address _
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