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[To be Returned to thev Circuit Clerk of, the “ County in which the Death Occurs.]
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Date ' of Deathy...,
Full Name'of Deceased,  & A <
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'If. Color,* Age, (It
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6. Nativity,
Ige, (last blrf hday), />.<■.  *
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Occupation,
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1 hereby certify that the above is a true return of the death and other facts above recorded.
Dated at....
County <g	■&.,..........Miss.,	s, f Mtending physician.
this ^L..Z^.day of... Yfis&kiJL'......, 187/
Residence,.....-..
words.
*	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
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