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

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€W UlSffli,
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
______	,	-Q-ra.^	<	__	. .
1. Month, clay and year of Birth, £................../A1^..	... I <fy........
2.	Sex,............................................... 'j/fati.aMr.....................:..
o.	Color, *.......... .......................,....._....................................._
Jf-. State if still'born, ........_-=»...».....*...../	■nuif’** Tn it'ljftii iii
5. Fall no,me of Father, ...................... ..... :....j	^y	GSV) (ULA^jQ- < 
5. Narne of" Mother previous to marriage,..................................................
7.	.Nativity of Father,	.,..................&jC!^.^J.l.v^..iAA^............
8. Nativity of Mother, ........... .... ............. -Ju	-p frt<6.. *......  
I hereby certify that the above is a true return of the Birth and other
facts above recorded.
Dated at________________________________________ . )	///> //	,	r^,
Count,, of ................I,.........., Miss., V'-............
/I;	’	i	f	A ttendiTiWl hiisician.
this J day of ...v/MAp..................187y . J	”
Residence.....Bdij	.................
* State whether White, Black, Mulatto, Indian or other Races.	i
f Strike out these words if the Return be made by some other person, and add other explanatory words.