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.	Full-Name .of Deceased^...
3.	Sex,	.
4.	Color*...
5.	Age, (last birthday),
6.	Nativity,.	^..................
7.	0cc7/,pation//'^ "
8.	Disease,...................................~..»....................
1 hereby certify that the cwove is a, true "return of the deafh and other
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facts above recorded.	1	.	*	/
Dated at....	|
County ./•	 Miss.,')	y? f MUnAing physieum.
th is	day	of, 187^ .)
Residence,..........................:...'....1----.
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* State whether White, Black, Mulatto, Indian or other Race3.	i
f Strike out these words if the Return be made by some other person, and add other explanatory words.
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