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THE FACE OF THIS D O C U M E N T HAS A COLORED B A C K G R O U N D - NOT A WHITE B A C K G R O U N D

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County *f . r^r? STATE BOARD O F HEALTH
Vat. Pet. vr-.i-fijL ^ ° B u r e a u o l Vt-..i ca
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CERTIFICATE OF BIRTH
•ror :- v.-'-- ;C^. ,
Crtyof,-
.Sf. Registration District No..^.l5--wL.-5f2 Ml* S o . 1
10912
No,.„.....;;;n... "JgJjEZ'
-Word.
Primary Registration District ~Not$L.&Ur._£..__.jLttlJ Bogftered So
I f WrtS occurs In a hospital or other institution ••"'..-;•• .•-' ~ .-, -•/£•
give name of Bams, Instead of street and number,
2 FULL NAME O F CHILD...! *&k&£zs4akz

9
5 Twin, rfr Number
3 sex of I Legiti- Triplet ——- : / in order.. IB Of
Child if Kali mate? or other? of birth
To be answered in case of plural births only
birth
(Month) " ( B a y ) : •.'fSSSBS

NAME- FA,THEft? MAIDEN /// -'>'' MOTHER

MOTH!
NAME
• /• • Mf JUL&*!•••* S.i
9BQST 15 P O S T O n - tOE V "
•a o Mi s -r. J- - v ' ^ i t c
r*f
I S *•! "o 10 COX.OS 1! A S E A I 1 4 S T 'V* IS COI.OB 17 AGE A T XAST
f 1 X $ OB EEBTHDAY. 5 OB . ' BIBTHUATr..„__
f * ?"2 BACK (Years) RACE -/ (Tears)
1 12 B E B T S K C A C E , IS EIBTHP31ACE / 7
6 £=
•- «< 13 O C CVE ATION ;
U' & ^ ....--£
13 OCCUPATION
>'--C -i. ..-'!' f" I

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a
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9

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o * 30 Number of chad of thiBi mother.
ZH2i .21 Number of chUdrenxpf this mother, now Hying,...—
I 2 2 CERTIFICATE O F ATTENDING PHYSICIAN OR MIDV^EE*
jj 23 : hereby certify that I attended the birth of ihls child, and thatif occured on ......„./.!:..'-'...'......O.ft 1 . ..., I9J^ at.*?
( 'When there was no attenatajr physician } 25 Was this child bora allir«?...\. _s : :....
ft s -(holder,
or midwife,
etc^, then the males
should father,this
m o t hreturn.
e r , house- \
Signature)
~ // <r\/
• /
26 Period of ntexo'(Testation.
II 27 Came of stillbirth......
( i f Ki
Wife fc (Physician or Midwife)

A A , 24 Mlod
AddredB

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••••'•

THE BACK OF THIS D O C U M E N T C O N T A I N S AN A R T I F I C I A L W A T E R M A R K - HOLD AT AN ANGLE TO VIEW

I, Sandra J. Davis, State Registrar of Vital Statistics, hereby certify this to be a true and correct copy of the certificate of birth, death, marriage or divorce of the person
therein named, and that the original certificate is registered under the file number shown. IpJastimony thereof I have hereunto subscribed my name and caused the
official seal of the Office of Vital Statistics to be affixed at Frankfort, Kentucky this /-% l£(l day of Z^t{JT , 20_(

Sandra .T Tlflvia^Stntp Rpcnct