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

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[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
1.	Month, clay and year of Birth,
2.	Sex, ... .............................
3.	Color, *..............................
Jf. -State if still-born, ...
• /o
5. Fall name of Father,
5. Name of Mother previous to marriage,............................
7.	Nativity of Father, .....................................................•• ••• •'
8.	Nativity of Mother,	...dyr*...............................
1 hereby certify that the above is a true return of the Birth and other
facts above recorded.
Dated at
County of\	r:v	........., Miss., >
this.	day	of.
Residence...
* State whether AVhite, Black, Mulatto, Indian or other Races.	1
f Strike out these words if the Return be made by some other person, and add other explanatory words.
t Attending Physician.
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