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|"Registration of Birth and Color," State of Virginia form
Pages:1 of 1
|University of Albany, SUNY,
Estabrook, SPE,XMS 80.9 Bx 1
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)
Full name [dashed line]
Birth place [dashed line] *Color[dashed line]
Full maiden name [dashed line]
Birth place [dashed line] *Color [dashed line]
*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.
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
Copyright 1999-2004: Cold Spring Harbor Laboratory; American Philosophical Society; Truman State University; Rockefeller Archive Center/Rockefeller University; University of Albany, State University of New York; National Park Service, Statue of Liberty National Monument; University College, London; International Center of Photography; Archiv zur Geschichte der Max-Planck-Gesellschaft, Berlin-Dahlem; and Special Collections, University of Tennessee, Knoxville.
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