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Avegisuars ltecora ol liirtlis County of State Board of Health
State of Mississippi
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Voting Precinct j—
Registrar’s Register No._
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or Village, or City_ (Hospital) _
Date of Birth Vl/tt*'/______/ $
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Full Name of Child.
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Sex.
.Color.
Full Name of Father.
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Mother’s Full Malden Name
Full P. Address
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iss' (<¥rt	____
Born Alive?.
Name and Address of Attendant_______!.
or Stillborn?.
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Date Certif. Piled /'A
Date mailed to State Department or Co. H. Officer.
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Registrar.
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Address
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Voting Precinct.
Registrar’s Register No.
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or Village or Clty../ffi. (Hospital)___________________(j
Date of Birth	. 19 /? y	A
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Full Name of Child.
Sex
_ Color
Full Name (1/	/	/*	f	f?	.
of Father	i—____
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Legitimate
Mother’s Full	/	'7*7
Maiden Kama //?	i^C>	[V.
Full P. Address
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Name and Addri of Attendant
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Date Certif. Filed.
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Date mailed to State Department or Co. H. Officer .
Registrar. J&L.
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Address j