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It has not been edited and may therefore contain several errors.

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©1 JP®
[To be Returned to tho Circuit Clerk of the County in which the Death Occurs.]
....................» © •-------------------------
1.	Date of Death,	...^^51.............................., 18%.L.
2.	Full Name of Deceased,........................t
yZ>
8.	Sex,	.....................
St
u
4 - Color," /da<^
5.	Age, (last hi rttul (t.y)	^.....
G. Nativity,................................................................................
7.	Occupation,.......—...
8.	Disease, ...........................................:...
1 hereby certify that the above is a true return of the death and other facts above r ecorded.
Dated at....
County	..-..........ff'^f’MtSS^ Physician,
this.4$Lj/......day of....y^.&2r6^:L....., 18%}..
Residence,...........
*	State whether White, Black, Mulatto, Indian or other Races.
f Strike out these words if the Return bo made by some other person, and add other explanatory
words.