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

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•■■■ , . . ' : ft* :?!%&'> [To be''Returned to the Circuit Clerk of/1 tlie County ’in which the Death Occurs.]
1 ■ ^ m" * .r;,.. ■____________________________________________ ■ &&
1. Date of Death,  X O.f^L. .1
2. Full Name of Deceased, fa.tf
. 1 Bex,.
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'/ta'eh....
Jf. Color,*'...........................
I	1	'	,	,y	yjjjjgj
5.	Age, (last hlrLhdaij), ..3'J
6.	Nativity......fy.YMj.....................
7.	Occupation,.......J/ / /'f.c.J S •	................
'V: i
>. Disease,	...• .—
1 hereby certify that, the above is a true return of the death and other facts above recorded.
Dated at..........................................’.^.i...
County of. —	£js.c,....................Miss.,
this...............day of...Mk(lh.t:A....,.......t,
Residence, iy\
.MPtfau.........:i;v/ .:.
t Attending j^Jiysiciarfc ^
1	•:. i - VJP
1 t..........................
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* 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.	■	t!r-,y.	•»-.. ■
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