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County of
State Board of Health	-	^	J-'a State of Mississippi
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Voting Precinct.
Registrar’s Register No._ o-&>r
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Bom In
Voting Precinct, or Village, or City.
Date of Birth
Full Nami of Child
Mother’s
Maiden
Sex
Full Name of Fa
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Legitimated
P.M.
of Fathei
Full P. Address
Born Alive?.
Name a: of Attei
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_or Stillborn?.
Date Certif. Filed.
Date mailed to State Department or Co. H. Officer.
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(Hospital).
Registrar’s Register No. JAi .
-41
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Date of Birth.	-KM_____PM.
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FuU P. O. Address _
Bom AUve?_
.or Stillborn?.
Name and Addresser Zr / of Attendant_____CP vfl-
Date Certif. FUed.
.19.
Date maUed to State Department or Co. H. Officer.
.19.
Registrar..
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