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[To be Returned to the Circuit Clerk of; the ,County in which the Death Occurs.]
• •--------:--------------
1.	Date of Death, ............................................................., 187-j
2.	Full Name of Deceased,
S. Sex,..........................
Jh Color;-.....
I
5.	Age, (last birtliJLfiy),
»
6.	Nativity......
...Occupation,
8. Disease, C
1 hereby certify tluit the above is a, true return of the death and other facts above recorded.
f Adtendiyg Physician.
Dated at
f.
this....,../ u day of
County of.....^r^...................Miss.,
...., 187j?. Residence.........
* 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
words.