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

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MMfiTORjLWIflfi' #af SIlIBWSHi?#
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
1. 'Month, day and, year of Iti rth	.. '
2.	Sex-,./t'tlL..................................
3.	Color, *......................................
Jf. Slats if still-born, ..
5. Full name of Father,	...................
5. Name of Mother previous to m.arviage,^.&&bh!^
7.	Nativity of Father, ....	.t....................................
8.	Nativity of Mother, ....or	...............................
I hereby certify that the above is a true return of the Birth and other
facts above recorded.
Dated at	J?.	........	f/7/I?	’
Count// of	....., Miss., ,• ....tz' .r fr; ..nl ■ .
' ^	/	i	v	T_JLUwttbwg-P-hysician.
this day of	8^0. J
* 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.