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[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
1.	Month, day and year of Birth,..
2.	Sex,
3.	/.Color, *..(*/.
Jf. State if still-born,
5. Full name of Father,	.....K.....
5. Name of Mother -previous to marriage,.......................
7.	Nativity of Father,.......C<Q.^^..t,.....................................
8.	Nativity of Mother, ................................................:....
I hereby certify that the above is a true return of the Birth and other-facts above recorded.
Dated at 7^**7	^.....
County ofC$?^'	.. ., Miss.,
this..
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~Z......"j?" ’	;	f	Attending	Physician*.	.
Residence......... ...................c?/
*.....	rr
*	State whether White, Black, Mulatto, Indian or other llaces. f Strike out these words if the Return be made by some other person, and add other explanatory words.
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