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

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©S* MDtWIlg®
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
1.	Month, day and year of I>irth,....	j?/.. .............................
S. Sex,.........
M
8.	Color, *.......................................................................;;..... 
If. State if still-born,......................................
" Fat her,
5. Full name of
5. Name of Mother previous to marriage,. .......M/^....$./t.
7.	Nativity of Father', ...
8.	Nativity of Mother, ........................................................
I hereby certify that the above is a true return of the Birth and other
facts above recorded.
Dated at County of ., this.../
........ 1
,Miss., !■
..day of....j&*^L/?r....187^.,. J
Residence.....
►4,
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.