This text was obtained via automated optical character recognition.
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.]
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1. Date of Death,.......^
2.	IpjjTX-jYanie of Deceased Sex,.........J&dsz
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., 187/..
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f Color * ...¥Mi
5.	Age, (last birthd<t,y),	..
6,	Nativity, :^^3dkdk.%^o>k^....(^^A.....^3^..............................
&B#r Ocmvpation,^-^^
J ■ 	•	V'y-a	-'-.il. !>,y • *	...-.	—- <^--.
8. Disease,	..<^tu^e£
1 hereby certify that the above is a'true return of tfie death and other facts above recorded.	;it£
Dated at............................ .
County of	{0tn~.:....Miss.,,
litis....^..x^day of......., 187^.
Residence,.....!.:.
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* State whether White, Black, Mulatto, Indian or' other Races.
f Strike out these words if the Return be made by some other person, ahd add other explanatory words.
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