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

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[To be Returned to the. Oirouit Clerk of the County in which the Death Occurs.]
1.	Date of Death,..
2.	Full Xante of I)eeeas ed,	.
3. Sex,	........ .................  ......:.....
Jf. Color;- ...	...........il..;	.	.
5. Age, (las I birthday),	&t
6.	Nativity,...
7.	"-■ Occupation^.
8.	Disease, /{jz..
4- -----------—....18%.....■
J-
;i ; ft ^r'rl ■' '*'■■
M: *
1 hereby certify that She above%s' a, true return of the death and other-facts above recorded.	y*7"
Da,ted at.,..
County of................... ..........
this....^...^ri.dft'! of...............,
Residence,
t Attending PJitrsician.
* State whether White, Black, Mulatto, Indian or«other Races.	i
f Strike out these words if the Return be made by some other person, and add other explanatory
words.	*'Sffc:..	.