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

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AVI®!!’ ■©!? BIWWW®
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
1.	Month, day and year of Birth,	 'J>A...7r,A<t/
2.	Sex,	......
S. Color, *......
Jf. State if still-born,
5. Full name of Father, ....$-£^±1.^.. $	...........
y ■	vs	\
5. Name of Mother previous to marriage,..........................
7.	Nativity of Father, CQ? /a '?-yz>	^	r_____	_________
8.	Nativity of Mother, ........^................(jftf #./..
I hereby certify that the above is a true return of the Birth and other-facts above recorded.
i.../4?#?v ..................
/Q y /	’	i	//	T Attending Physician*
this  day ofJtfrZ^rt:.:.... J 8 7f.... J	v
Residence.	............
* 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.