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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 j County in "which the Death Occurs.]
1.	Date of Death,,.
2.	Full Name of Deceased,. <p(^. ..................$, /2d.
3. Sex, -..,..
Jf. Color...
S. Age, (last birthday), ./athy,
...:........., 18U.
6.	Nativity,...........................c2}.^..^..
7.	Occupation., .............. ................
' \ '\r:
Disease,	..0&.&aaUi!3Z£34l&&S<i&L«^	.....	: dk j
—®-------- -------------	~----  i-..	■.	.i.j-.-v...,,	..	...	•...■.	.....	 .,'
I hereby certify tha,t':'bhe above1 is "aHrile return of tlie death and. other > ,Vr facts above recorded.
Da,ted a I...	//l'3ts?X*r.. .....:... 
County of.............................................Miss.,)
..:.(..?.J...1.u
this..
v.Jprz. day of.	f,
.., 18U-.1
^ P _
t Attending Physician.
. -? ■ ■'A
Residence,
i'-y
*	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.