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

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*w*wuiral #•*•■*“•■■
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■julliitt]
[To be Returned to the Circuit Clerk of the County, an which the Death Occurs.]
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1.	Date' of Death,
2.	Full Name- of Deceased,........r:
3. Sex, . .	 !.......
Jf . Color,*	......
5.	Age, (last birthday),
6. Nativity......
7.	Occupation,
8.	Disease,....^
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..............................................................................................................,~
1 hereby certify that the above is a true return of the death and other facts above recorded.	Vv-''
Dated at ...........................................j
County of. ..............................Miss.,)
this ..J?da,if of....y*?^4Z~~, , 187^..\
liesiden ce,	..,.......................
*	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.
t Attending Physician.
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