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

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®H®>isai'AeisBr ,®p atiBWiis®
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
|i. Month, day and year of Birth,.
i2.: Sex,.
. ////
[S. •■ Color, *....................
' ‘ | ^ ' ' '
'// . State'if still-born,  .- —«—...............;• .1
; «, i ■ ■■ 1 t
",5. Full name of Father, .	({$&'
5. . Name of Mother previous to marriage,j...............................
7. Nativity of Father, ^1.
8. Nativity of Mother, <7a	A'-a-w	^	,	■*
I hereby certify that the above is a true return of the Birth and other
facts above recorded. Dated at	l.</_
County of...,
this...c&...%~.....day pf\.J$:&*T6dL...........18%f . .J
., Miss., 1
t Attending Physician.
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.