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

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[To be Returned to the Circuit Clerk of the County in which the Death Occurs.] ---------------------------------* fb—•------------------------------
1.	Date of Death,	.........................................
2.	Full Name of Deceased,.............
3.	..Sex,.....................„J...,...............
Jf. (Mor? ...a/At'd 1............*...  1;..:... Lll
c&i
'■vyf,
Age, (last birthday),.
*» •
5.
G. Nativity,.....^^^^....‘^£2.1
/r
7.	Occupation, {
8.	Disease,
1 hereby certify that the above is a, true return of the death and other facts above recorded.
County of...J*	^...Miss.,
this
day of,s.
.,187
Residence,
c^pf Attending Physician^
m
kb*?!
'y.)i
■Xw
■	~!M,
■	S
. .......................................................................?..............
* 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.
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