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

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x®:! /.Brattst*
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[To be Returned tq, the ^Circuit Clerk ,:of the Coiinty in which the Death Occurs.]
»	.i': yX y 'y-	:t	, .''iK*
1. i .Date of De.atJi]
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2. FitII;,A‘u me: of Deceased,,?/:. 8. Sex,......
■x-7.--'Decupdtidiv} 8. Disease, ......
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5. Age, (last'birthday ),    j.................................
; - ;.£■/ , ^ ^ v
6.	Nativity ,x....,C
1 hereby certify that the above is citrue return of the death and other facts above recorded.	■
Dated	....
County of,.............................Miss.,
this <$&....> da,y of. ,18 7^.
Residence,......
+ Attendirig Physician.
V
*	State whether White, Black, Mulatto, Indian or other Races.	i	.
t Strike out these words if the Return be made by some other person, and add other explanatory words!	1	■' I'
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