This text was obtained via automated optical character recognition.
It has not been edited and may therefore contain several errors.

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:©gllklll*a«l#»I|! ■ ®>k jur'wstwnuB*
[To be Returned ^to the Circuit ■ Clerk .of the County in which the Death Occurs.]
" -■------- -----—_i! : : 
■I- //-
/£>■
1.	Date \ of [Death,...
• 2. ^Full 'Name of .Deceased,	....
■ ■*"’ ■ ! -<>j	■	'•	‘	''is	/I	■	!
..,187/...
\ o.
; Sex,
r'%h£2k		•,	
*; . /"v		[ j -i
15. Age, (last hirtt/.day),
tV /.
Occupation,....
8.	Disease,..
1 hereby certify that the above is ct, true return of'the death and other facts cibove recorded.
Dated at.......................................
County of....rV^C,....................Miss.,
this.../ff?.....dan/ of..............., 18%£>...,
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.