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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.]
V t . ■■'■J	i":	,	i	/
..•'..I
11.	Date ,of Death,,.......................................................,................, 187Jr.
I .	G	o	.	-V	V	/	t______^____	■	/
I i?/ Full Name of	..
I	■'! r'	^	'-i s?	'■	i-->	■'	'vH:	'	‘
o.	: Sex,
| lf;. : Color,*... /^
15. Age, (last birthday),	..................
: 6. Nativity,.........
7.	Occupation,
8.	Disease,
1 hereby certify that the above is co true return of the death and other facts above recorded.	■	■
Dated at A7.<ud, t,. .^i^
County of....^^^^-	.....Miss.,
this±«^..C4n^^hiAj of..Z2pdLtt4^-..■■>. 18 7/fc..
Residence,........*..
1 ii 'J
*	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.	:	.