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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 Clerki of ther-County in which the Death Occurs.]
.,L	<	'	0	-/..l.-	-	...	ii	'.i	*
1.	Dale o/ De.allf,...........id....,.&
!	•.**.; y .--r .Zfc' ;
2.	'Full %Name of Deceased,,.............
l	  187 Z..
. *' \ • V r i	-I •
i1;1 . ■:■ : ^ r :.	7 V '
	J\ ,.. •
$. 'SCX,
Color*.........„,...>
i ;	r	'■■■'!•'	v
■5. Age, (last birth do.y),....
6.	Nativity,...........:1:
7.	Occupation,^,................
%. Disease, .....
1 hereby certify that the above is a true return of the death and other facts above recorded.	/?
Dated at.. ..
Co unty	^	ytoTtnirti^
tJils .s^.x/....day of..../ZrZZL^.,, 18 T^tO
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.