Asylum Hill Patient Information

Share your information

• Do you consent to have the information you provide here entered into the Asylum Hill Research Consortium database, which will be available to the Asylum Hill Research Consortium and other vetted scholars for purposes of research about the project?
• Do you understand that your name and contact information will not be shared with researchers without your express permission?
• Do you agree that any photos, documents, or other files or information uploaded to this site will be made available to Asylum Hill Researchers through the Asylum Hill Database, which will be available through this website?

If you do not agree to these terms, please do not enter your information here. If you have questions, please contact Lida Gibson.

* = Required Fields

Contact information
Name*
Address*
City/State/Zip Code* City   State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code -
Home Phone	() -
Cell Phone	() -
Email Address
Asylum patient information
Name
Your connection to patient (great great granddaughter, etc.)
Date of patient's birth (if known)
Patient's place of birth (if known)
Date of patient's death (if known)
Patient's place of death (if known)
Patient's place of burial (if known)
Patient's home county (if known)
Date of patient's admission to the asylum (if known)
Date of patient's discharge from the asylum (if known)
Was the patient married?	Yes No Maybe
Patient's spouse's name
Did the patient have children?	Yes No Maybe
Number of children and children's names (if known)
Please give us more information or comments about your relative and his/her association with the Mississippi State Asylum.
If you have documents or photos you would like to share, please upload them here.	*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf, *.gif,*.jpg,*.jpeg,*.bmp,*.png,*.tif,*.tiff
If you have any additional information to share, please add it here.