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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.]
!	-;---------:---0^9--------------------
ik,..t^z:/S'//£^.................................., :is%p...
1.	Date of. Death,
f • (
2.	■ Full Name of Deceased,:
Jf. Color*........................
5.	Age, (la.sl hirthda.y*),..
0.	Nativity,..........................................................................
8.	Disease,.........................
/
1 hereby certify that the above is a, trae return of the death and other facts above r ecorded.	.	:
Da,ted at  ;..................................;; 
County of...^^/:^hdr. ^>-	.......Miss.,
this >r~.......d.ay of..	W	■	'	c^t>
Residence,.
, 4>,.
rfHtrnd ing t PIitjjs i iTt.ll ft r
..... ,
* 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.