This text was obtained via automated optical character recognition.
It has not been edited and may therefore contain several errors.

---

/■
ififi
D©ii
'JBL
'	r|r 'I*	‘	1
[To be'flReturned to the Circuit Cleric of('ithef County in "which the Death Occurs.]
'-i'.-l	•	\	'■	Ji	'	■	'-A':	1)	'
i I
		
1.	Date of ‘Death,!.
2.	Full Name'of Deceased-
If. Color
' ,! ‘‘j* ’ .<
5.	Age, (last birthday),	.
6. Nativity, ..................................u:.L,..;.....„j....^„......,.„.ii.:.. 
7.	Occupation,.............te**5&I
8.	Disease,
X	I ’	i .
7 hereby certify that the above is a, true ret urn of the death and othei
facts'.above recorded.
Dated	 -......)	•	,.
County	..Miss.,
this....Z.A.^...:. day of p.
* 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
'	^	;	'W-	_______	■	...	'
-------1''-y-!.-1	:	---“-------
words