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

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SBMMNBAVKON’ 0F UIIIIWHS.
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
1. Month, day and year of Birth,...,..........................
4^,.....
Color, *....
I/*. i State if still-born,
5. Full name of Father, ......................
5. Name of Mother previous to
7.	Nativity of Father, ................................................................L..,.::......:...
8. * Nativity of Mother, ...	.................:....
I hereby certify that the above is a truelreturn of the Birth and other facts above recorded.	■
:
Dated at	., j
County of,	.....,Miss.,
this ... •f"/z£duy of^J&^j^^ _18%.J... J
• Residence.......;.........
t -AMendvn^F^frysician
* State whether White, Black, Mulatto, Indian or other Kaces.
f Strike out these words if the Keturn be made by some other person, and add other explanatory words.