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

---

MMglSKAWlSK US1 'jtllliWIlS.
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
1.	Month, day ancl year of Birth,.........
2.	Sex,
o.	Color, *....................................................
If. State if still-born,______^__r...............................
5. Fnil name of Father,	..	......
5. Maine of Mother previous to marriage,.	t-
7.	Nativity of Father, ...../ZtZ....................................................
S. 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	*'?/.&&	.........,Miss., i
lay of..	.18^.0... J
Residence ..
.....
t Attending Physician
* State whether White, Black, Mulatto, Indian or other Ilaces.
f Strike out these words if the Return be made by some other person, and add other explanatory words.