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State Board of Health
Registrar’s Record of Births
County of
State of Mississippi
Bom In
Voting Precinct. or Village, or City_ (Hospital)________
Registrar’s Register No._
AX
Born In
Voting Precinct.
Registrar’s Register No-
it' s-c /i___________
A±
r
J2.
/i
<2L
Date of Birth.
_______19_Jl %L
/i'
.A.M.
.PJVt.
Full Name X /	/	/?	ft?	fi
of Child (<ZtX J^~eC <(?\	Aye.
Sex
Full Name of Father ^ L
Mother’s Full Maiden Name
Full P. O. Address ^
Date of Birth	*7	^AJiS.__________________P.M.
^	*	J t- s	. ^ i.
Full Name of Child_
Sex.
Full Name of Father
.Color.
Mother’s Full Maiden Namec
Full P. O. Address _
Born Alive?
Name and Addp of Attendant
Date Certif. Filed
Bom Alive ?_
_-^T>
_or Stillborn?
Date mailed to ...
State Department kL
or Co. II. orrioory/Hc*'t^<_a, & ^ G
Name and AddreSs^ of Attendant ~ />'^1
Date Certif. Filed
Date mailed to /. State Department or Oo. II. orriooi
Registrar Address.^*
Registrar.
Address.