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State Board of Healt
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Registrar’s Record of Births . aa County of M** * ctf*'
^	~	State	of	Mississippi
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Born In
Voting Precinct
Registrar’s Register No..
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or Village__________
or City (Hospital)
Date of Birth.
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.P.M.
1_____Color____Legitimate ?
Pull Name of Father
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Mother’s Malden"' Nami
Full P. O?/ * AddressV^t?
Born Alive?
Name and Add* of Attendani
Date Certif. Filed _L
Date mailed to State Department \l^ / / or Co. H. Officer V
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Born In
Voting Precinct, or Village, or City. (Hospital)_____
Registrar’s Register No_
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Date of Birth
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Full Name of Child_
Sex
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.Color.
legitimate?
Full Name of Father^
Mother'
Maiden
’s Full /~L	j	(Li
n Name	at	/	rtl
FuU P. O. Address
Bom Alive?_
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or Stillborn?.
Address.
Name and Add of Attendant.
Date Certif. Filed.
Date mailed to State Department or Co. H. Officer.
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Address
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