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Get Mississippi Vital Statistics - Mississippi State Department Of Health - Msdh Ms

PRINT IN BLACK INK DATE(S) OF SERVICE Month Day Year Month 1. Date Service Began: ENTITY PR OVIDING TREATMENT Day Year 2. Date Service Ended: 3. Name: (If not hospital or clinic, give address or other identification) 4. County: 5. City or Town: Inside City Limits? Yes No PATIENT INFORMATION 6. Race (Check only one box) 1 White 2 Black 7. Age: 8. Married? 3 American Indian 9. Education Yes No 4 Other (Specify) (Specify only HIG.

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