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[To be Returned to the Circuit Clerk of the County in which the Death' Occurs.]
, d±t?-
1.	Date of Dea.th,....................../.........l/.dJ'ft.c.
2.	Full Name of Deceased
8.	Sex, ^	..................:..
. 'jf. Color * &A*2yr..I;.......................:■. .! 
. /____________ *
5.	Age, (last birthday),.....
G. Nativity,........*/ Z^Z^J
itsM:A^c	011 ^	t	’	■	v	-	,	•*■♦<•	*	'■	*t»-
S. Disease, .....
1 hereby certify tha.t the above is a, true return of the death and other facts above recorded.
Da,ted at...^
County of-this../.
v............Miss.,,
I j	_ „	. (
^§£....du,y of.../''/yp^<p^r'.., 18fy0 .)
Residence,..............
...,,...,
t Attending Physician.
* State whether White, Black, Mulatto, Indian or other Races.	t
f Strike out these words if the Return be made by some other person, and add other explanatory
words.
i ■
••••■• -.1______________________________________