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

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®SB«§I§«AW1®M ®JF aillWIIiS®
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
7. Month, clay and.fy ear of Birth, u 2. Sea,
S. , Color, *...
If. State if still-born, ......................... ......................................
5. Full name of Father,	^ ...........................................
5. Name of Mother previous to marriage,_________________________________________________
7. Nativity of Father, /£&
8. Nativity of Mother, ...............//.......... .....................................
I hereby certify that the above is a true return of the Birth and other
facts above recorded.
Dated at	?s
County of
this.../. ?r '..day of .....ft
Residence
, Miss., > " -187f... j
C' ir,
t Attending Physician.
* 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.