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State Board of Health
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Registrar’s Record of Births^»,
County of
State of Mississippi
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Born In
Registrar’s Register No. MIX
Voting Precinct	OsVLsC	vIT^K________________________
or Village______________________________________________________
or City.	Jit i
(Hospital)__________
Date of Birth.
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Voting Precinct, or Village, or City (Hospital)______
Registrar’s Register No-
/73
Sex_
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.Color.
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Legitimate?
Full Name of Father
Mother’s Full Maiden Name
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Full Address
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Born Alive?
Name and Adi of Attendant
Date Certif. Filed
Date mailed to State Department or Co. H. Officer.
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Registrar.
Date of Birth.
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Full Name of Child
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Sex,
_Color_
Full Name of Father
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Mother’s Full Maiden Nam
Bom Alive?.
Name and Addra of Attendant.
_or Stillborn?.
Date Certif. Filed.
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Date mailed to State Department or Co. H. Officer _
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Registrar.
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