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

---

OF SIBTOte*
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
i£f,
J. Month, day and year of Birth, ......................................ft...
%. Sex,.......................
3. Color, *....^A^AZ.....
Jf. State if still-born,
5. Full name of Father, ......L<............-^u^irr................................_
5. Name of Mother previous to marriage,
7.	Nativity of. Father, .....$&&'}',......................................
8.	Nativity of Mother,	..........................
1 hereby certify that the above is a true return of the Birth and other
facts above recorded.
Dated at -	......... ,
(Jounit/ of	w. t'tcjS/O.,Miss., • ..	.	•
J i/-*	/}	yi	,	’	|	//	f	Attending	Ffnjsician.
this / t*-......day of.	..-.18%.0. J
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 other explanatory words.