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 ijfrcuit Clerk of .1 the Oounty in which the Death Occurs.]
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1.	Date of Death,	.................^......~~~.-.........:...,
2.	Full Name of Deceased,...........................
3.	Sex, .	^	.......;...........^..................
Jh Color*.............................................'..............
j . ■ .
5.	Age, (last birthday),....
6.	Nativity,......
7.	....w.	..,	....
8.	Disease, .....
1 hereby certify that/the above is ctHrup.'retuim of the death and other facts above recorded.
Dated at..
County of.......iss., |	IdSi
this.... ^
...day of I
* State whether White, Black, Mulatto, Indian or other Races, f Strike out these words if the Return be made by some othe, words.
esidence,..