This text was obtained via automated optical character recognition.
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	:	—	:-h	•—-----------------—
1.	Date of Death,.	............................>
2.	Full Name of Deceased,
3.	Sex,	.........,..j..
Jf. Colo r, * ...................... {4.......
' ............../?..
S. Age, (last birthday), ....^C;
G. Nativity,.....^>.4
7. Occupation., —-—-
8	._Disease,
1 hereby certify that the above is a true return of the death and other facts above recorded.
Dated at..............................f.......)
County of.............................; Miss.,
this...........da,y of...J^/^. .&&r?.., 18 % I .)
Residence,...........
t Attending Physician.
■ 1
*	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.	•	I