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

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J
jMCIMH-AWiaW OT mvin.
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
1.	Month, day and year of Birth,
2.	Sex, ..
3.	Color, *..
J/,. State if still-born,
5. Fall name of Father,
5. Name of Mother previous to marriage,..
/. S/Jrs......
7.	Nativity 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 County of
this...	clay	of	--/2^.,
Residence
Q Fhym
* State whether White, Black, Mulatto, Indian or oilier Races.
f Strike out these words if the Return be made by some other person, and add other explanatory words.