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Registrar’s Record of Births
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County of
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of Mississippi
Registrar’s Register No. / / / Bom In	/
Voting Prpnlnp.t	_____________________________
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Sex
Full Name of Father
Mother’s Full Maiden Name
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Address < /
Born Alive?
Name and JfL of Attenda
Date Certif. Filed.
Date mailed to State Department or Co. H. Officer.
Legitimate ?
Registrar
Address.
Born In
Voting Precinct, or Village.
Registrar’s Register No_
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(Hospital)
or City. jSL. /2^~ cLeyyjsty
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Date of Birth
Full Name of Child.
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.Legitimate?
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Address.
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Name and Addri of Attendant
Date Certif. Filed
Date mailed to _ State Departmeni or Co. H. Offi6er
Registrar
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Address