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

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/ ''
am®KS»®ATX®Bi ©* aiiniWHiS.
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
1.	Month, clay and year of Birth,.
...............
2.	Sea
o.
Color
» * .................
If. State if still-born,
5. Full name of Father,
5. Name of Mother previous to marriage,.
Jr ^ ................................................
7. Nativity of Father,
8. Nativity of Mother, .. (y]	k (Xj)..CU,.
L hereby certify that the above is a true return of the Birth ancl other
facts above recorded.
Dated at	...........
County <>f	........, Miss., •
this..day ()f.J^Ci:2?(^...................,181)0. J
Residence	....................
* State whether AYhite, 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.
t Attending Physician.