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

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'.m* msafwmr	*pr«.	/KPQAMNBfe
[To be Returned to the Circuit Clerk of the County in which the Death Occurs.]
.1. Date of Death,.......	//	^	....................., 18%/
2.	Full Name of Deceased,
8.	Sex,.......................
Jj. Color*......................
5.	Age, (last birthday),....,
6.	Nativity,
7.	Occupation,.....*- ^
8.	Disease,....
1 hereby certify tha,t the above is a•, true return of the death and othei facts above recorded.
J ‘./ ,	’(	//	r Attending Physician,
this .da,y of\ /V fy*^*................f 18%/ .)	"
Residence,
* State whether White, Black, Mulatto, Indian or other Races.
t Strike out these words if the Return be made by some other person, and add other explanatory
words.