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.: . i 1 ■ , ■’ ''■ i v?r~. ./’ [To be returned to the Cirdtiit Clerk,of the County in'which the Birth occurs.!
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<1. 'Month, day and year of Birth^MS^^
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; I hereby certify that-the-above is a ' facts above recorded.	;■	<-',\	.
Dated at_____..............................
County of ... la:/('a /^.evc/h   Miss.,
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this....i.i:.....day of.................1187/..., J
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Residence............LL........,
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%0-tlendinQ Physician* i
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* State whether White, Black, Mulatto, Indian or other Eaces. . i ; '	.
f Strike out these words if the Return be made by some other persorj^ahd add other explanatory words.
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