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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 which the Death Occurs.]
1. Date of Death, .
2.	Fjdl Name of Deceased,
3. ISexr. £^AJL£l.......................:  . . .’1 4
Jr. Color*.......................;.	........
5.	Age, (last birthday).....fZl/.f/....u.....u
6.	Nativity,.....
7.	Occupation,
8.	Disease, ....
1 hereby certify that the above is a true return of the death and other-facts above recorded.
Dated at,.^^	.......
County of.	.Jlfiss.,)
..........,187,
11/1	/	day	of
f Attending Physician..
Residence,...........................................x
* State whether White, Black, Mulatto, Indian or other Races.	,
| Strike out these words if the Return be made by some other person, and add other explanatory
words.