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

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j™*
[To bo Returned to the Circuit Clerk' of' the County in which the Death Occurs.]
! ■'"t 1 . i	—------------:--rr----0:;r®—6>-
1. Date of Deathf. i. .-..Li  
Full Name of Deceased,,............
/:C:	*1'
3.	Sex, ......4..........i.v- -:.................-juW/ZMg.
^.	Color*—......'XJ.....kl
.	Age, (last	birthday), J.~
6.	Nativity,..............;.....1:
4 :•
•K,
7"-«
■5
.....\.BMinZJ.±A............
.....,/...J> t/V-
...........
7.	- Occupation,.........^..............................:.:...
8.	Disease, ............:..!............... '.................v......•....
I hereby certify that the above is a true return of the death and other ' facts above recorded. .	■	'''
Da,ted at  ...................,................................)'	„/.l
County of...........................Mis#:,
this..X™......da,y of...oMd^......., 187</.
Residence,
t Attending Physician.
* 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.