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») casiKiit' 'sg^Hsa	wg'dSB	'•sap'	•	i	^sp-Ksy	e*s^' '-'SB*' ««!i 'ses'essflsissss'®
[To be Returned to the Circuit ( Clerk of, tho County in which the Death Occurs.]
17. Date * of Death,....j*6
■%. Full Name of Deceased,.......
S. Sex,	...............................................
\;Jf. Color*...................,.»4.i...:J..:...!...„......
\S. Age, (last birthday)
1.87fi.
'6. ' Nativity y...^Z.
7.	Occupation,
8.	Disease, ...../J5i<4*tdOi
V'
1 hereby certify that the above is a true return of the death ctncl ot^Sf facts above recorded.	.	'
Dated	................
County of.....d$!*^..*d(rp&._..................Miss.,
this.	. ..da,-]) of...
, 187?.... Residence,.........“....L,-
f Attending Physician.
* State whether White, Black, Mulatto, Indian or other Races.
t Strike out these words if the Return be made by some pther person, and add other explanatory
words.	jf	j• ■