This text was obtained via automated optical character recognition.
It has not been edited and may therefore contain several errors.

---

1131**11®.
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
1. Month, day and year of .tV{rth.,..£l^A/<V'&j •fSz:,...........................
.2. Sex-,	.............:...............lu.:..,;:.;. .  :.............
,:3.' Color,	............- 
Jj-. State if still-born,	.......
5. Full name of Father,
5. Name of Mother previous to ma,rria,&ey
7.	J\rativity of Father, .......'
8. Nativity of Mother, ..................!/...
I hereby certify that the above is a true return of the Birth and other facts above recorded.
Dated at /'Z*a	........
County of	..., Miss.,
this.../~/77^: d(iy	......18%/. . J,
Residence......,.............
t Attending Physician.
* State whether AVhite, Black, Mulatto, Indian or other Races.
f Strike out these words if the Return be made by some other person, and add other explanatory words.