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AjiaB,, aBi^p w<ab • mm mtw.'m&am *pm mw w<®s> wsukbi^-#
[To be Returned to the Circuit Clerk of the County in which the Death Occurs.]
1.	Date of Death,:
2.	Fall Name of Deceased,
3.	Sex,...;..^.................
Jf. Color*....2?.2^:cy^-
187
5. Age, (last birthday),..
G. Nativity........
7.	Occupation,	...........
8. Disease,.........
■. v-V .
■v'N -i."-:
1 hereby certify that the above is atrue return of the death and other facts above recorded.
Da,ted at ........................................!.)
County	............Miss.,)
this...^........daV of...J^pr..........., I87f\	: ^
Residence,....................................................■--: ’
* State whether White, Black, Mulatto, Indian or other Races.	1	_	^
t Strike out these words if the Return be made by some other person, and add other explanatory
words.
Attending Physician.