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.]
7.	Month, day and year of Birth,
2.	Sex, ../&'/*. &.......................
3. Color, *................................
Jf. Shade if still-born,..........■- ......
5. Fall name of Father,
5. Marne of Mother previous to marriage,..
?.. Nativity of Father,	...:L.:..:....
8.	Nativity of Mother, .	f -z.t-z-u	,
I hereby certify that the above is a true return of the Birth and other facts above recorded.
Dated at	a	............
Miss.,
County of.....
this..............day of. JZZ/^p^..........187?.... j
Residence <-a /'s-'PwiJ
* 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.