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

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IliHS'ISBAWIHH &W JIIJMMS,,
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
1.	Month, day and year of Birth,.
2} Sex,	...................
3. Color, *	.....	........
-feState 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	.......
County of .........................Miss., ■
this j£%s*-?'/~d(Ly of...18 7................ J
Residence c/±
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.