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

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[To be returned to the Circuit Cleric of the Courity in which the Birth occurs.]
ajl&i......- .../6tL.
1.	f: Month, day and year of .Birth,
k I
p. ;; Color,.*..7!7^/l-ty(Z'...
\. i Slate if still-born,
j: I-';!.. KS! .	^	/	/T*	/\	v-v	/
I). Full name oj^ JF'cbHb&j* 9
15. Name of Mother previous to marriage,'.......................................................   
// /
7.	Nativity of Father,	..
8.	Nativity of Mother, ^...............................{pQ.c^,........."	••'■
1 hereby certify that the above is a true return of the Birth and other
■ ! - ' facts above recorded.	u	;:	;	v	i
Dated at _.....■................................
County of.............................., Miss., ■
this..
v^C... day of,.j3&^t:.*£^...18%.{.. J
Residence........j...........
..
t Attending Physician.
* State whether White, Black, Mulatto, Indian or other Iiaces.	1
f Strike out these words if the Return be made by some other person, and add other explanatory words.