Hendry, Sylvia Anne
State Board of Health
Bureau of Vital Statistics
1. PLACE'OF BIRTH:
(8) County C/A-~-L.~---"" - -<0 / DJstrict No.
(b) Precinct PreclDctNo
~tenAme; not number)
(c) Cityor - Cit7or;)
TO/_"--"~ TownNo.c:..7
Name of hospital or insti
~/ <...--4/. --
(If not in hospital or institution, give street number or ocation)
CERTIFICATE OF BIRTH
FLORIDA
State File No.
./:J .L -::4: .
Registrar's No. ,~~ ,/ (..
2. USUAL BES~CE OJ' 1l40TBl1:B:
(a) stat<> ~
(b) County ~.- ./
(0) City or To&~. ... --< ..-<~.;>-
(If outside ci~~ town limits, 'Jrlte RURAL)
(d) StreetNo. y t/.,t:. ~.tA_~eI' C~" -
(If rural. give location)
Mother's stay before delivery:
In hospital or 1nstitution Tn this community
(Specify whether years, months or d&y8) .
'"
3. J!'ULL NAllIIE OF CHILD
t. Date of birth / ,.j..
. (month)
021
(day)
B. Legitimate?
'7,;#--, .
/'1
C7. {~~
, 16. Color or race ./ 17. ~ at time o. f thisl1Y:th. ~ .ys.
18. BirthplaC(' ,. t..~d-~"'~ &-. .( ~ . '
(City, town or county) (state or foreign country)
19. Usual occupation ./ toL- , .f ·
20. Industry or buslnes-
21. Children born to this mother: 22. Mother's mailing address for regiatution notil'.e:
(a) How many OTHER chlldren of this mother are DOW liVIng? -V
(b) How many OTHER children were born alive but DOW dead?
(c) Row many OTHER chlldren were born dead
9. Full name
(Date of)
24. (S1gDed)
21. or (Signed.)
26. .Adcireu
ft. J'I1~
CL&.~/ lot' M. on the
d?:::l::::atill~ ;A-c.v-/3'" A/~- "..:.// (r /
J / /
0(' c:/,';)".' ,<j:_" (~ /' ~ D
_ _ . __ .-". .. -4-.r"1/. M..
~-,-.t:1t-~ "--c-- -a--r Midwife
,/ ~ 19 'V c~ /'J-l. (/6 ~Ct:.. ~i~-G""'" i'\.
, c/ ~ Reg1Strar -
23. I hereby certify that I attended the birth of tbilI oh11d, who w"
date above stated and that the information given was furDiIhed by.
related to this cbJld as c?n~~
28. Given name added from a supplemer1tal report
By