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.]
• • 4ft----------------*
.. . • •
1. Date of Death,;......
2. Full Name'of Deceased....:
.)■ ■ ;
8. ' Sex,...
Color
.., 18%-
\Jfr' .
•	X	J	')	*	’J* •
5. Age, (last birt hday j, ...,
‘ 2.......,
6. Nativity
....X- ■TlMciipc(f ioU;
8. Disease, ....../
1 hereby certify tha,t the above is a true return of the death and other
facts above recorded.
Dated at.....Ist/i ll^AS
County of
this...A.rrz:...daAj of.
x/As....... ..Missf,
y!=z..., is^j:
Residence,;...
' f Attending .Physician.
* State whether White, Black, Mulatto, Indian or other Races.	i
t Strike out these words if the Return be made by some other person, and add other explanatory
words.	1-::	: