/Volumes/T7 Shield/EWP/Elements/EWP_Files/source/Ingest One/4 Faculty Staff and PTAs/4-5_Lists_and_Teacher_Cards/4-5_White_Teacher_Cards/EWP_Hansbarger_Margaret_Lee_01.jpg
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de-
formity on back of certificate and
write OVER on front.
If child is deformed describe
WRITE PLAINLY, WITH UNFADING BLACK INK (WRITING FLUID)—THIS IS A PERMANENT RECORD
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THE OTHER, No. 2, etc.,in question 5.
e ————————————————————————————— e e
.lefi M Witness to signature‘
Date rec by reg
CERTIFICATE OF BIRTH
Department of Commerce COMMONWEALTH OF VIRGINIA
Bureau of the Census DEPARTMENT OF HEALTH .
BUREAU OF VITAL STATISTICS Registered No.
—_fi_——_fi__fi——'-———__~———————_—=————-fi&%—_—" ——
. PLACE@ BIRTH , G, . USUAL RESIDENCE OF MOTHEB
/ Registration
(a) County__ District No. (a) State
For reg. use
(b) County.
(c¢) City or town
(d) Name of hospital or institution 1) X (d) Street no.
(e) Is place of residence within corporate limits? \ ;é__
o If child is not yet
. Full nare of chld_ Y QYT | S_Ed_r () € S e 40T T Tnamed;leave blank:
Boy ] L%
. or . 5. Twin or If so, born 1st, 6. Months 7. Is mot marn
Girl Triplet___~ 2nd,or3rd_______ of preg- to father
Write word of child?
FATHER OF CHILD
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. Full name_\__J1Q 2 dCo/l) A hS NV b,
N
10. Color or rzit ln = 13 Age at time ofthis birth_y_# , /FS.
12. Birthpiace L { ] 3 e o hPoOc h U YV V9,
City,(\gwn, or county State gf fdreign country ) ‘
13. Usual occupation : : 19. Usual occupation