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

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TTo be returned to the Circuit Clerk of the County in which the Birth occurs.]
^7	„
1.	Month, day and year of Birth,
2.	(Sex,	.........................................................
3.	Color, *.................................................v....................
Jf. State ifgiill-born, ...................S......................................
5. Fall name,of Fcither,..........................................................
5. Name of 'Mother previous to marriage,
CK, " v ^
7.	Nativity of Father,......^	.....
8.	Nativity of Mother, .............................................................
.7 hereby certify that the above is a true return of the Birth and other
facts above recorded.	*
Dated at	........ 1
Co un ty of. .......................} Miss., I-
thiss^...£..^rday	.....18 % 0. J
Residence
t Attending Physician,
* 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.