1321:
"Registration of Birth and Color," State of Virginia form
Date:
1924
Pages:1 of 1
Source:
University of Albany, SUNY, Estabrook, SPE,XMS 80.9 Bx 1
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&quote;Registration of Birth and Color,&quote; State of Virginia form

REGISTRATION OF BIRTH AND COLOR Full name[dashed line](Give name first. Give full maiden name if married woman or widow.) Place of birth[dashed line]sex[dashed line] Date of Birth Name of Husband[dashed line](If married woman or widow) Father Full name [dashed line] Birth place [dashed line] *Color[dashed line] Mother Full maiden name [dashed line] Birth place [dashed line] *Color [dashed line] Remarks: *A white person is one with no trace whatsoever of blood of another race, except that one with one-sixteenth of the blood of the American Indian, unmixed with another race, may be classed as white. Form 59-3-17-24-65M. I hereby affirm that I believe the statements as to color of parents on the other side of this card are correct and that I am signing this with the knowledge that the penalty for making a false statement as to color is one year in the penitentiary. Signature of registrant [dashed line] Address of registrant [dashed line] Witness to signature [dashed line] Address of witness [dashed line] *Signature of physician [dashed line] If not signed by registrant state kinship of signer [dashed line] Place of filing [dashed line] Date of filing [dashed line] If the person signing the statement cannot write, he or she must make a mark between the given name and the last name, Thus his (her) *If the doctor present at birth signs, it will be accepted as to age for labor, school, etc. John X Doe Mark [end]

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