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State Board of Health
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Kegistrar’s Kecord of Births
County of
State of Mississippi
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Born In
Voting Precinct-or Village, or City_ (Hospital)__________
Registrar's Register No._
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Date of Birth
Pull Name 0	„	-■1	Q./	/
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Full Name fj —	-')/	S—
of Father ■ ’ . C. (; .. V< /p-'T	__________________
Mother’s Full ^
Maiden Name / ~ 11 l.
Full P. O.
Address
Born Alive?
Name and Address: of Attendant
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Date Certif. FUed
Date mailed to Btate or Co,
Department /S	/	■	.
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Registrar.
Address.
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Born In Voting Precinct
Registrar’s Register No_
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or Village, or City_ (Hospital)_________
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Date of Birth JoV-g-Full Name />
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Mother’s Full ■Maiden Name.
Legitimate?
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Address -OV W	^y/-	A
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or Stillborn?-
Date Certif. Filed.
Date mailed to
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Address
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