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[To be returned to the Circuit Clerk of the Coui||f?^™jfelrl.he>Birl^j^^cur#]
1.	Month, day and year of Birth,...............
2.	Sex, ..../?<
Color, ................................
Jt. State if still-born, ....**.............
5. Fnil name of Father,
5. Na,me of Mother previous to marriage,........nfe
7.	: Nativity of Father, .	...........
8.	Nativity of Mother, ........Say/s,.....................7S/£z^?'f- £r:.
I hereby certify that the above is a true return of the Birth and other facts above recorded.
t,his .day	..18%  J
Residence........................
* State whether AVhite, Black, Mulatto, Indian or oilier Races, f Strike out these words if the Return be made by some other persi
*■