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

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,i/:^
w] iimwiiis
[To be returned to the Circuit Cleric of the County in which the Birth occurs.]
1. Month, clay and year
of Birth,..	/ rjz:. fi..
O
O.
Color, *
Jf. State if still-born,
A ■
5. Full name of Father, .. 
5. Name of Mother previous to in drriage,
7. Nativity of Father,* ...................................... ^.....^...t..
8.	Nativity of .Mother, .......................................y..*:..,K..................
.7 hereby certify that the above is a true return of the Birth and other
.tj'V’
facts above recorded.	^
Dated at	^	7^-? -i, a 7^-Z^J....£....
County of ^7^ i-	......Miss.,
tliis,,T^--£:f ™t/day of-j£^bi77..........187Jit... j
Residence „..cx<77c'...i
f- 'vibtonding Physician-(
* State whether White, Black, Mulatto, Indian or oLher Races.
f Strike out these words if the Return be made by.some other person, and add other explanatory words.