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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 ofi the County in'"which the Death Occurs,]
-	■-.:■!	■■■	■, 7
1.	rdEpate of Deathy
2.	Full Name, of deceased,
3.	Sex,
Jf. Color f.
..Aim, (last birtjiday),.
7 ' ' ■..........-
(L Nativity, t
7.	Occupation,
8.	Disease,....
1 hereby certify that the above is a trite' return of th& death and other facts above recorded.'
’ Dated at..:.
4 Miss.,
County of.
this..c^Jlt^day of....87
' f ‘ ' '
Residence,4*4
j „ mm.
u'y(	"	t	Atlsn-diTi^PIujsioiaiL.	A:' ’'s
) 77-. Un	/O	..y,,	.
■’•: "-'^5 -■ ::v-v^'l9ll
............... ,
*	State whether White, Black, Mulatto, Indian or otherjRaces. y ■	;	•.	'-1'	v'-- ;
t Strike out these words if the Return be made by son$e other person, and add other explanatory ' words- ■ ■ - ■