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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.]
. ~-----e
1. Date of Death, ..................../?	77^.:i...   .......
2. Full Name of Deceased, Z&i
187/...
o.
Sex
,.........I:
Jt. Color,*....
Age; (last birtHcldfy);::&
6.	Nativity,..
5.
/.
Occupation,
8. Disease,.....As? 'fai.fr..............
1 hereby certify that the' above' is a true return of the death and other
r	'’V	'
facts above recorded. . ’
Dated at.............................................|	j%J%
County	..it,*- Miss'...........^ YMtendiM£ Physician.
/7 •	,/	^yy	7	/»	^7y	■
this....x.-77-r,..day 0/id,
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