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Registrar’s Record of Births
,	County	of	7
State Board of Health''"*'s'
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Bom In
Voting Precinct . or Village.
Registrar’s Register No.
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(Hospital)
or City /Soy s&r£“
Date of Birth
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Sex	_ Color.
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Legitimate ?
Full Name of Father.
Mother’s Full Cs i	(Lty
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Full P. O. Address _
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Born Alive?
Name and Ai of Attendant
Date Certif. FUed
or Stillborn?.
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Date maUed to Btatfl Department or Oo. II. Glflner
Registrar.
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Address _
SJate of Mississippi
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Born In
Voting Precinct, or Village, or City. (Hospital)_________
Registrar’s Register No_
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Date of Birth
FuU Name of ChUcL
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FuU Name of Father.
Mother’s Maiden Name
FuU P, Address
Bom Alive ?_
Sex	ajtx~-	Color
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Name and Address. /
.or StlUbom?.
of Attendant.
Date Certif. FUed.
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Date maUed to State Department or Oo. 11. Of floor
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Address
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