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

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jma«as®A®|i®K #a? nivis.
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
..a/^ ~/?7
	
1.	Month, clay and year of Birth,,
2.	Sex,
8.	Color, *.
Jf. State if still-born,
5. Fall name of Father,   
5. Name of Mother previous to marriage t
7.	Nativity,of Father,............................................
8. Nativity of Mother,	^	.j „
1 hereby certify that the above is a true return of the Birth and other
facts above recorded.
.Dated at
County of	....., Miss., [■ .....
/? 4?	\	T	A	ttencivng	1	tnjsician,
is.
1877. J
this.. it:... ...clay of...
Residence
*	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.
T