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

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e»5S(*'!5P'(jp£*. WKBvmm,' ibswj	mu ■ 'wikvhl, jump 'wu'wsbj ikkmsmm^j.®
[To be Returned to the Circuit Clerk of i the County in which the Death Occurs.]
Ih,...............................-
1.	Date of Death
2. Full Name of .I)eceas ed,,r	f/t,L
s. sex,      v.....................................::j.;i.... £ ,..., i_*
J/>. Color*..............................:......!..:.....;.r_.:„......,.:
5.	Age, (last birthday),..:...,	J
6.	Nativity,
....:., m.j?
,/C	:
8. Disease, ....
1 hereby certify that the above is a, true return of the death and other facts above recorded.
Da,led at,
Miss.,
(
County of..‘
thisJ^l^l.....day of...&*..£•
Residen ce,........,.......t..
f Attending Physician.
*	State whether White, Black, Mulatto, Indian or other Races.
■ t Strike out these words if the Return be made by some other person, and add other explanatory
words.	1	,