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

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»30®IS®A,r»lI®M OP 111111*11®.
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
1. Month, day and year of Birtli,..^^^^^^..^^:.... /J-//.
2. Sex,, ................................ ....................
S. Color, *...................................................
Jf. State if still-born,
5. Fall name of Father,	£•£<?..,	........................
5. Name of Mother previous to marriage,...................
7. Nativity of “Father, — 
8.	Nativity of Mother,	.........................................
1 hereby cettify that the above is a true return of the Birth and other
facts above recorded.
.Dated at	............. ] n/f	/\
Comity of. £%^-A	......., Miss., !• ......yT(...■£•-••-^^-----7..........;.
J y~	/2	1	//	T Attending Physician.
this.../ ,r......day of.	187f. J u
________Residence QX^> .......................................
* 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.