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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 fin which the Death Occurs.]
1.	Date ' of' Deal//.;.:..
2.	Full Name of Deceased,
... k .
S. Sex, 
If. Color,*'.
5.	Age, (last birthday), ...i
6.	Nativity,.....
7.	Occupation,
8. Disease,
........., .1.8%0 .
I:]...;.;..;......
■'iWli:'
. ‘i
1 hereby certify that the above is a I rue-return of the death and othei facts above recorded.	...
S' / '---------"	'
Da,ted, at..	.;..  )
Miss.,, .f ^ttencling Physician
■.	-y..*
this ..jZ /^^d.u,y of...
Residence,
*	State whether White, Black, Mulatto, Indian or other'Ra0^V ;, .	,
t Strike out these words if the Return be made by some qther;porson, and add other explanatory
words.	'	.