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Registrar’s Record of Births/, ,/d 9	•J'V,	County	of	*
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Registrar's Register No._
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Date of Birth
Full Name of Child
Sex
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Mother’s Full Malden Name ._
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Address.
Born Alive?_
Name and Adtfrfe: of Attendant
Date Certif. Filed
Date mailed to State Department or Co. H. Officer.
or Stillborn?.
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Registrar Address Jl
State of Mississippi
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Born In
Voting Precinct.
Registrar’s Register No. d'f
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or Village_________
or City (Hospital)____________
Date of Birth
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Full Name Qsia of Child r'i
Sex
Full Name of Father.
Mother’s Full Maiden Nami
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Full P. Address
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Born Alive?_____
Name and Address of Attendant
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Date Certif. Filed
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Date mailed to State Department or Co. H. Officer/
Address
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