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

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I #f% Beat
■	tfejM lyg^^jjyg11!! vmKMBU . t -•■ug'	iwi.yiiBi,[cg».!8)
[To be Returned to the Circuit Clerk of the County in which the Death Occurs.]
1.	Date of Death,
2.	Full Name of Deceased,.......r.
3.	Sex,......:......
.4, Color*!.........;:j...................l..................
. \v I-1'*..: . ' ■>'	,	.	:	1	'
Age, (last birthday), ...i...............
'.it*; - 1 *
•	•	\S
5.
t
G. Nativity,,
$VuU ,........................................................................................
1 hereby certify that the above is a true return of the death and other facts above recorded.
Dated at....;..................,...........)	frtOrt/Pi,
County of.................A,.......Miss.,(	-j-	JLttsndA^g^hysician.
this...JA/jL....'day	....., 1S7/.J,.
Residence,
*	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.
.r.'-Mi-VS