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

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#■* HJO&WW®.
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
1.
1.	Month, clay and year of Birth,.
2.	Sex, .. ...................
8.	Color, *.....
If. State if still-born, ....---
5. Full name of Father, ...
5. Name of Mother previous to marriage,.............................
7.	Nativity of Father,	t....c.................
8.	Nativity of Mother, ....... v> ...i...:....................n ........."...,.........
/ hereby certify that the above is a true return of the Birth a,ncl other
fads above recorded.
t	J	—^
]
Dated at
County of yZA:*-*-'1-	......, Miss., 1-
this...^ day of....M^i................18%A. j
Residence ,::;y
Attending Fhysician.
* State whether White, Black, Mulatto, Indian or other Races.
[ Strike out these words if the Return be made by some other person, and add other explanatory words.