This text was obtained via automated optical character recognition.
It has not been edited and may therefore contain several errors.

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®£B®ISRyA,WJ®If ©I1 limiPIIS
[To be returned to the Circuit Cleric of the County in which the Birth occurs.]
o'
1.	Month, day and year of Birth,.
2.	-Sex, .
o.
Color,
ST
If. State if still-born,	..........
5. Full name of Father, .........y;-‘Vy„
5. Name of Mother previous to marriage,..............................................
7.	Nativity of Father,-z~	....
8.	Nativity of Mother, ............................................,...............
I hereby certify that the above is a true return of the Birth and other
facts above recorded.
* 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.