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AWKMST #*
©
[To be returned to the Circuit Clerk of the Count Vain which the Birth occurs.]
________________________________^_________________
os/Pt
1.	Month, clay and year of Birth,................................................y....v..m....£'.~:..
2.	Sex,......................................
8.	Color, *..................................
If. Sta,te if still-born,  "!	.........
5. Fall name- of Father, i 5. Maine of Mother previous to marriage,
7.	Nativity of Father, ........./CZx,......................./%, fofasyn.
8.	Nativity of Mother, ...........................................,..............................
I hereby certify that the above is a true return of the Birth and other
facts above recorded.
Dated, at	___
Co uni ty o f	^ - ? r ^	.}	Miss.,
t Attending Physician..
this../’ c^L(t((,y of....^£^.^.,....18%A. J
Residence
* State whether White, Black, Mulatto, Indian or other Races.
'[ Strike out these words if the Return be made by some other person, ^d*a^jd other explanatory words.
' ~~	K.......