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

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ma®iM®A|»*®i9r ®w aimwai®®
[To be returned to the Circuit Clerlcof the County in which the Birth occurs.]
./If*
1.	Month, day and year of Birth,.........
SeX, ..............................................................................
8.	Color, *..........................1.......... C.................................... 
If. State if still-born, .... up-—r.::................................................L:.  ..-
S. Fnil name of Father,   .............................................................-
5. Name of Mother previous to nmrrlage,
Nativity of. Father,
8.	Nativity of Mother, C(J>
I hereby certify that the above is a true return of the Birth and other
facts abovey recorded.
Dated at /^/rf'y7'^7<^rV^L	.......
County of	......., Miss., •
this.../...jr-..day of..../^<^?^~_____18%0.. J
Residence......................
t Attending Physician,
* 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.