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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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Voting Precinct
Registrar’s Register No._
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or Village_________
or City ^ Osi. (Hospital)_________
Date of Birth
Full Name of Child
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Sex	_	Color.	Legitimate?
Full Name -	✓O	/?	.
Full Name of Fathi
Mother’s Full Malden Name
Full P. Address
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Registrar
Address
Born Alive?
Name and Adi of Attendant
Date Certif. Filed
Date mailed to State Department oi*" Co. H. Officer
Bom In
Voting Precinct
Registrar’s Register No_
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Date of Birth.
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Full Name of Child_______
Sex _
Full Name of Father'
______Color. or . Legitimate?
Full p. Address
Bom Alive?
Name and Addr of Attendant
Date Certif. Filed.
Date mailed to State Department or Co. H. Officer
Registrar.
Address
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