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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.]
.. '■ ♦- (
1.	Date of Death,I ................................................................ ............., .18HA
'J i
2. Full Name'of Deceased,  '
3.	Sex,...
Jf. Color
5. Age, (last birthday), ..  L3 J..0L
6.	Nativity,
,.U4..
Occupation,
8.	Disease,
1 hereby certify that the above is a true return of the death ctnd other facts above recorded.
Dated	......,........)
County of. .................................Miss.,.
this....,/.^?....day of..	......', 18 %0 .)
Residence, -*-V	...........................
*	State whether White, Black, Mulatto, Indian or other Races.	,	,
f Strike out these words if the Return be made by some other person, and add other explanatory words.	'	,J	'
^ J.
f Attending Physician.