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

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[TcTbe returned to the Circuit Clerk of the County in which the Birth occurs.]
z...zi
1. Month, day and year of Birth,.............:l.-i
S. Color, ..............................
" ‘	f t
If. Stats if still-born, .......
i- /
5. Full name of Father, ..
5. Marne of Mother previous to ntfirriage,	//
7.	^Jfatilrity of+1?cither,	..........................................
8. Nativity of Mother, ........... C'/fi'.
I hereby certify that the above is a true return of the Birth and other
facts above recorded.
Dated at r .	_
County of
this............day of..
Residence
Zt'??
$M. ttending Flfijsiciaii.
* State whether White, Black, Mulatto, Indian or other Races.	•
|- Strike out these words if the Return be made by some other person, and add other explanatory words.