This text was obtained via automated optical character recognition.
It has not been edited and may therefore contain several errors.

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11	.villi,
[To be Returned	to the Circuit	Clerk.-idf	the	County	in which the Death Occurs.];
■ ■ / v '■	■ :—- —--------:-/ ,■ '*	—®---:—. ‘	--
1. Date of Death, L	......................., 187-/t-
1 Full- Nair&ypf^Deceasecl, •.................. . ....................... ...:—---
8.	pJSeX, ...,.^^^^.^^,1^1-1:.........,.^...£:LL :...L.......................-.........
'If. . Color *..................................................!.....:.1.:..
!	;&07	2j	^	!	^	,
5.	Age, (last jfiirthClciy),... ^^ s&wte*. <?	: ' ^
*• ;-:v . •*- Y •
■;
U -j,v
s
*13
...tLACi..
0.	Nativity,
7	' Occupation- ‘ -'. cf —	r	’. -■■■?■■■•
^ . V ' / h' /Z	" />-/ '
8.	Disease,
1 hereby certify that the above is a true return of the death and otlu^ facts above recorded.
Da,ted
County of.~
lhis.....y/!£Z^r(l(l 1/ Of.....tfttrtr.jr.*.*.. ,
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 Sgplanatosrj/ words.
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