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

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. IlJIffllSISAWI'OK O* MIIiWHS.
[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
1.	MontJb, day and year of Birth,..
2.	Sex,...
3.	Color, *.......................................................................
Jf. Sta ts if still-horn,..........................................................
5. Full name of Father,	.......................................
5. Name of Mother previous to marriage,..,.........................................
7.	Nativity of Father,
8.	Nativity of Mother,
1 hereby certify that the above is a true return of the Birth and other
facts above recorded.
Dated at	......... ]
-d t'ti-n tl-t njj I
County of.........................., Miss.,
this-. ^^t-T^'duy of....j3:f.#^'£l^L'...l87J
Residence ...
'■ $
. ^ m
*	State whether White, Blaclc, Mulatto, Indian or other Ilaces.	1
f Strike out these words if the Eeturn be made by some other person, and add other explanatory words.
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