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

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4—+-
:£$W BEBVHB.
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yfK /TTo be returned to the Circuit Clerk 6f, the County in which the Birth‘'occurs. 1
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1. .Month', clay and year of Birth
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g. "	.Mil...............
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3. Color,*	.....
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Jf. •• State’ if still-born, ,/fL^.J^^.:^.
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'5*. Full name of Father, ...
.5. Name of Mother previous to marriage,
||,/^,N<^ivUy ^f ■ftad'h&r.,	„..v;.............•;
' S. Nativity oj Mother,
: I hereby certify that Hie above is a true:f^lrii of tin
'nl'imip y'(>nni^r}pd	’	.
i of the Birth and' ollteF
facts above recorded.
Dated at	.,
County of ilii*s
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Z...•.., Miss.,
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Residence
%$&nding Physician».£
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* State whether White, Black, Mulatto, Indian or oLher Races.	*	i’	‘ i
f Strike out these words if the Return be'ma4e by some other person, and add other explanatory words.