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State Board of H
flO n Registrar’s Record of Births
^ County of u	Z3
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ate of Mississippi
^7	...____
Born In
Voting Precinct
or Village, or Clty_ (Hospital)__________
Registrar’s Register No.. /CO
Date of Birth ^__________________________*21____19 &L____________ _A.M__________P.M.
Pull Name ^4<of Chili
Sex.
9vc
.Color
Or-
.Legitimate
Full Name of Father
Mother’s Pull Malden Nami
Full P. O. Address
Born Alive?
Name and Addri of Attendant
Date Certif. Filed
Date mailed to State Department or Co. H. Officer.
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Addri
Born In
Voting Precinct_______t G/?
Reglstrar’s Register No-
-ILL
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or Village _ or City_ (Hospital)_________
Date of Birth
19^^________A-M. P.M.
Sex.
7>^W4.
2L
_ Color.
Or"
.legitimate?
Pull Name of Fathe
Mother’s Pull fl, /7 0 —-J~ Maiden Wnma	t
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CL cT
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Pull P. O. Address
Bom Alive?
Name and Adi of Attendant
Date Certif. Filed.
Date mailed to State Department or Co. H. Officer
Registrar Address 0.
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