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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 Clerk of the County in which the Death Occurs.]
7.	Date of Death)...
'*.*<■ :
it-1".
2l\?Full Name of Deceased,
3. M...................................... .................
Jh Color*............................................ ...'..|
5.	Age, (last birth d-ay),.......
6.	Nativity,......
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i ■
7.	Occupation
8.	Disease, ....	...............
1 hereby certify that the above is a true return of the death and, other facts above recorded.
Datjpd. at..................................,......)
Co unty of-..,c^.^A.i^:<fcZ^............  Miss., /
this.. 6^..... ...day of..
t Attending Physician.
..,
Residence,..
* 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.		;i		
• : ■ -r- ■ ■ : . ■ ,-j		v:: !,-.v "		■1 • L .V-! ti.