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

---

[To be returned to tlie Circuit Clerk of the County in which the Birth occurs.]
J. Month, day and year of Birth,
2.	Sex,	^..........................
3.	Color, *.....
Jf, State if still-born,
./
5. Full name of ' Father, ..	 
5. Name of Mother previous to ■
7.	Nativity of Father,.......j .	..
8.	Nativity of Mother, ............ i<...................;.!_l.........(.<.......a..
I hereby certify that the above is a true return of the Birth and other
facts above recorded,
Dated at	..............
County of	£p-.......... ., Miss., •
//Z.....day of.
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.