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

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iiBfiiis»jy»|i®ir of birwms®
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
...^
.*r
1.	Month, day and year of Birth,................
2.	Sex, ...
8.	Color,
Jf. State if still-born,
■i-
5. Full name of Father,	QJlM-*/.-'?
/ /
5. Name of Mother previous to marriage,^
7.	Nativity of Father,
<4^ *..
8.	Nativity of Mother, ...........
y // //	.......i.
I hereby certify that the above is a true return of the Birth and other facts above recorded.
Dated at - puff/M
County of............................, Miss., •
this...X£.......day of........................ J
Residence
A ttmtflvftfl J/hrf/rVi^ri.
* 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.