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It has not been edited and may therefore contain several errors.

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oy O.
CS® KIKWHS.
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
of Birth, //'fr'P.
2.	Sex,.....	.............
1. Month, day and year UJ	v,
.a	'
r.
Colot
■, *................................A?
Jf. State if still-born, ..,
5. Full name of Father,	...................................
5. Name of Mother previous to marriage,.........
7. Nativity of Father,     	/^Lro^ty.. ^
8. Nativity of Mother,
I hereby certify that the above is a true return of the Birth and other
facts above recorded:
Dated, at	..........
County of. >\/>a(A'..............., Miss.,
this../J day of\...^^ki^6............18 %fl. J
Residence...<s?rY ^
t Attending Physician.
* State whether White, Black, Mulatto, Indian or oilier Races.
i' Strike out these words if the Return be made by some other person, and add other explanatory words.