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

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OS MPWMS.
ylffijpi the Birth occurs.]
1.	Month, day and year of Birth,..........
Z. Sea , .
.^5/k.
o.
Color
lor, ......
Jf. Stale if still-born, .........................................
5. Full name of Father, ...
5. Name of Mother previous to marriage,.................
7. Nativity of Father,.....................................
S. Nativity of Mother,	et .........................U...................S’.
f
I hereby certify that the above is a true retui'n of the Birth and other facts above recorded.
Dated at	............ )
(\>mi tty of	.............,Miss., I .~~k
f Attending Physician.
Residence
* State whether White, Black, Mulatto, Indian or other Races,
f Strike out these words if the Return be made by some other person, and add explanatory words.