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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 i which the Death Occurs.]
187//
1.	Date of Death, ;............................
2.	(F&ll Name of Deceased,
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8. Sex,.....:dA.yZi.Ci:LA.,:....rl.
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4.	Color,*-...;....iLj.g'..
5.	Age, (last Mrthda.y)j ......
6.	Nativity,........i...................................:.;....
-7. Occupation, ........:::......................................
8. Disease, „...............
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1 hereby certify that the above is a true return of the death and other' facts above recorded. y
Da,ted at ..............................................)
County ofyyC^/...y<J..!.L:Li /f   Miss.,,	\ Attsndiiig^Physician.
this /./.........day of:.:../.#£../.   ,..., 187//}) ^	.
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*	State whether White, Black, Mulatto, Indian or other Races.
t Strike out these words if the Return be made by some other person, and add other explanatory words.	'■■■
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