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State Board of Heajth , dt/*4(j)
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Born In	LL	V
Voting Precinct_______________ixdTT
or Village
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(Hospital)
Date of Birth
Pull Name of Child
/^Registrar’s Record of Births ^ ^’ County of d> k — cP
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Registrar’s Register No_
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Full Name	_	.	-
of Father ( /? 'T.
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Full P. O. / Address / O' Le>
Name and Addri of Attendant
Date Certif. Filed.
Date mailed to State Department or Oo, 11, Offliw
Registrar_____l
Address