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FUNERAL ' RECORD' OF

Casket ~ ... R(l.!L.VI'.o..o..9: ...... .o._~......... .. (Style) (No.) Outside Case or Vault............................ .. Embalming Body ................................... . Professional Service ............................... . Hair Dresser............................................. . Suit or Dress .......................................... .. Shirt, Collar, Tie .................................... ..

'Yearly No •..._.. _.. l2~" .... _......_...

No•... _.. _.._.""._.._ . _ _

Name. ...... _........ _.... _......__ .._.... _M/;\!!)J.~.... I-t.@.~n ...... _.................................................S= ....~.e..m.:!l..~~

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Cause of Death0. '--'lC>d~.<'-"".... P.:/"l3.Lf.!..£.~ ....Contributory...................." ......................" ......".". Date of Death ...No-lJOember." ..11•."..l9.59.......................Hour... _.............?.;..3.Q... A.,.... Place of Death" ... ho.m.e... ".".......... "......... """_..... ,,........."...... .How Long Ill? .... " ......................................... _... . Physician......D.r ..".. G.•....ll.•"..alanken.~.bJ,p... " ............ Address ........." ....... :N..El.~..~.~..L ..III.Q ................

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Occupation of Deceased. ...... .J;W.v.s.e.v1.if.e .... "._ ..... " ......... SociaI Security No ............................................. . Name of Employer...............___ .__ ._____ ................_... _...... _.............................................................................................. . Address ............................................................................................................................................................................. .

Charge to............ ch.il.dr.en ................................................. ...Address ................................................................... Order Given By....... chl1 dr..ell .............................................Address....................................._.......................... . Date of FuneraL.No..v:.e.mb.er.....l;3.,.....195.9....................Time .........:.:......~.: .3...()....l? .~.IlI!.! Place of Funeral Service....l4ap.le....G:r..a.l(.e...G~.r.man ...aap..1;..~.§.t.. ...9.h~.r.(}.h ............................._. Clergyman........._.............. __..._ ........ __ .... _.... _....... ;....................~Call for? .............................................................._

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.. .. I Door Spray .............................................. .. Gloves $....................Chairs $.................... I Flowers $..................Palms $.................. I Cremation .................................................. Newspaper Notices ............................. _.. . Telephone and Telegraph........................ Ambulance ............................................... . Funeral Coach........................................... . Passenger Cars ......................................... . Pall Bearers' Service .............................. .. .. .......... Transferring Body.................................. .. Opening of Grave.................................... .. ............ Cemetery Charges .................................. .. Lot ............................................................ .. Misc. Transportation.............................. .. Shipping Charges .................................... Clergyman .............................................. .. Singers $................Organist $................ .. Cash Advanced ......................................... .

Totel Anl0unt. .......... : Remains to be shipped-see reverse for details.

Interment at..........D.1c..e....C.~m.e.1;.!;\r.y.................................................................................................................. Lot No ............................................. Section No ........................-.................... Grave No .............................................. .

Ramarks .................{l;;r.ay....f .(l.l.1;....~J.Q.y.I}... .:r.5>.\l.l1,S...e.!l.Cl......~t..~~~

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Permit Bill Rendered

Insurance ......................................................................................... . FORM allsa S UPERIOR FUNERAL S UPPLY CORP •• CLI:VEL:AND , OHIO •

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a:r.y:....Al::m ...S.ke.l..1i.QIl..............................................Sex..........f..~.!!l\l,.+..~.. Address................... _.. _........ _........ Q§.§.§.y..Ll:.b~.t ....M.1.!?.~g.~.~.~ ................................................................... . Name. ......_...................... _..........

COunty...Bar.ry........._.._.._.._...Townahip....... _.._...._... _...........................Phone N 0 •.•.••..•....••......••...•• _:............. . Where Born.........E.a;r.;r.y.......Q9JJ.!1:t;.Y..,... J!lJ.~.§.9l!,r.J.:

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Date of Birth......J.EDld§..r.J....

J.R.•..J:.??.7.9................Age....................~g..............................................._....... (Years)

(Months)

(Days)

How Long Resident in COmmunity..........................................._........... _.................. _.............................................. . Single....... _.._...•.......Married. ....................... Widowed... YI.±9:2!1:.~.~ivorced...................... Child........................... . Husband. Wife or Child of........................................._.................... _........ _............................ _.................._............... Address ......._...._........_.. __._._.... _.._.._............•..................................................... _.................................................... . Closest Relativ•....... .E.lm.er....Bk.e.l:t.an.......................... .Address ..............Q.a!?.~.y...tLl·.lh ...M g.-'........

...c..\!,r.:r.y............................... _.._,....Birthplace•...........:.........•....................................... Mother's Maiden Name... _MaJ:.:i;.Q,IiI....Hg!:ngr...................Birthplace..._...................................... _................. Father's Name....F.!:.~!21s.

Cause of Death......................................................... ~.. _. __. __ ... __.......Contributory__ ._ .. _.................. ___ .. __ ._ ........................ Date of Death... _No.v.emb.er. ... l l •.....l959.................... .Hour...................:j,J.l..3.Q...;P...!.M.~...... _............. Place of Death....Aur.ar...... HQSp.i:tal._........ _.............. .How Long Ill? ............................................... _....

Physician.D.r..•_.A. •....J. ..•....Q.,.....M9.~~.U.W.!L. ................. Address ....~~.r..()E!":.I... ..~I.l,.~ .~.~':l.r..:l: .......... Occupation of Deceased. .........Q,.QY.-.§.l?y!J.f.g ......_................Social Security No ............................................. . Name of Employer..........................................._... _...... _.............................................................................................. . Address................. _.................................................. _....................................................................................................... .

Charge to ........lns\,l~&nQ,tl... .& ... f.&IIlil.y...................... -Address .................................................................. . Order Given By.........f.amily.................. _.........................._...Address ................. _........................ _.................... .

DateofFunel~I. ....... N:Q~r.e:~t!e;~ ...1:i+.c.J,~!~3:.: ............ jr~rr'e... :: .. :~.'.:: .... ~!~~ . 2~~ ...~*:.,~~, ...........:

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Casket

Yearly No .... _......_.. _.......... _.......... .

(Style) (No.) Outside Case or Vault.............................. I.............. 1 ............ Embalming Body .................................... 1...... ......... 1..... . Professional Service ................................ 1............... 1..... . Hair Dresser.............................................. 1••...........• Suit or Dress ............................................ 1............. ··1 ..... . Shirt, Collar, Shoes $...................... Hose $...................... 1••••..•.••..••• 1•.•••• Underclothes Door Spray ................................................. Gloves $.................... Chairs $..._............... 1............ _.1 ...... Flowers $..................Palms , .................. 1............... 1 ...... Cremation ...................................................... 1•.• _....••• •• Newspaper Notices ................................. Telephone and Te:legra~lh ........................... J Ambulance Funeral '"'o:'cn: ............................................. 1 Passenger "a.co ...............................•........... 1....•.. _ ••••• 1..••••• •........... Pall Bearers' SeleYi"e ................................. J ............._. ............ Transferring Du.uY ..............•....... ................• 1 Opening of urav" .................................. _..... 1 Cemetery Lot .................................................................... 1............... 1....•• Misc. Trllnsportation .................................. J. ...... ........ J..... . Shipping Charges ...................................... 1 Clergyman ...... Organist f ............... ··11··.·........ 1.....•

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To~l Anloun~ .................................. .

Remains to be shipped-see reverse for details.

Interment at....... _ ~j,!'l-@..,a.l.....sprlngs....c.eme.t.e.r.y: ............................................................................... Lot No ............................................. Section No ............................................ G'rave No .............................................. . Ramarks····················g}ot-4.9-} ... ,r.Ucb.e.d ...Q;r>OO1Cl....G.il'\f.e.r ... sl:l&decl .................................. .

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FORM &2.a8 SUP-UfOJl JF U NER4L 8UPPLY CORP •• CLEVEC\ND , DHIO.

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Date. .......N9_y.e.m.R.e.L.l.? ~...195 9

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FUNERAL RECORD OF

Yearly No ............_............:),,?:L

No........_...•......_.. _..____

...

Casket

Outside cJ~t,;;e~ault {]::f..~".:)............ . Embalming Body ................................... . Professional Service ______.... _............... __... . Hair Dresser... _... __ .__ ..________ ....................... . Suit or Dress .......................... __ ............... . Shirt, Collar, Tie _____.................. __ .. ____ . ____ .. Shoes $...................... Hose $.................... .. Underclothes ...... ________ .__ ..___ .................. _.._

Name. ......_....... Ey..e.r.:t....AUm.aU ...................................................................................... Se:J:.!.~.~;!,~ ............... . Address................... St.s.r.k... C.ity..,.....Mi.s.£l9J.lr.L

.......................:................................................................

COonty .......:Ne,\!!.t.o.n............_ ..TOWllJlhip..................................................PhOIie No ............................................. Wh.re Born..................s.:tark....Gl.tJ[.,.... .M1a.sOl.U'.1... .........................Race.......wh.J.t .!)..........................

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Date of Birth. .......NQy..e.!1l.P..~..

r. ...?J.I....J.9..±.~.......... Age............._.........!±.~ .. _.... _................................ _....... (Years)

(Months)

(Days)

How Long Resident in Community.................. :........................... _........_..........................................._____ .__ .. __ ........... . · I .M • d. roo rr i -.rJ. d D' d Ch'ld S mg ............_.......... arne ......."'..........,...dowe ....................... Ivorce ...................... I .......................... ..

= " 11 Husband. Wite or Child ot.............................. =ma........ IDall......._............................ _................................... S t k C j, t M1 r1

Door Spray .... ____ ............................. _......... . Gloves $.................... Chairs $.................. .. FI $ P I $ owers .................. a ms .................. Cremation ................................................. .

Closest Relatlve._....c.~.de ... All man................................Addr.ss ...s..t .ar.!I;....Q.J:ty..•.;.. MJ .1? §9.lJ.r.;!. Father's Name.........CJ.¥.d.e...Al lman......................... _.....Birthplace..............................................................

Newspaper Notices .................................. I Telephone and Telegraph........................

Address ....... _.... _._..._ .. _.._ ............ _.._...._.................. ~.r.

...............Y..I............f:l.!'lgl\.............................................

.........Birt~ace..........' ................................................... .:.9.~;i...~ ~...........~.:':c;ntribu~~~ 6...... ~3.~.p.. p.Lt.M ·;J~.~. . .:. ..f~;. ...\: ..~ ;l ,' Cause of Death.'&~~:>.. ~ ..•.. :..~.!!.~.~ .......~!t1:,~.1 . . . . c..--.... " 0 Date of Death..·......·No.~mb.er. ... I "'., .... . ....",............Hour,..................... .x . ...... ... .. ....................... Place of Death......5.:t...J .Ohn.!.. S,.".,r.9.;p.l.l.n ..... .MO.., .......HoVi Long Ill ?..................................................... Phyaician ...... Dr.......J .o.e ... CD.ll.1ng .........................."....... Address ... ",.........J.:.Q.P.J.tn. ..... i!41.?·9..CllJ.F..* Occupation of Deceased. .... far.mer....................................... Social Security NO .....~ ....J .:.:: .. C? ....: ...I...~..... ~ Mother's Maiden N ame......,Mo.1l1e.....Ey..e;r.,t.........

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Charge to..........................................................................................Address ................................................................... Order Given By....f.a m.ily........................................................Address .................................................................. Date of F uneral. ........ ~J.,..ll!-"'J.~~~....................................Time ..................2....P..,..M.,.................................. .. Place of Funeral S.rvice...........stii\.I'k...C1.:ty....

e:tho.dis.t ....Cll:ur...ch.............................................

Clergyman ......... _.............. _.................. _..~.................................... :~~all fox:.?............................_____ .. _______ .______ ............._ Address... _...... _.................................................... _ ......................... ~_...... _............................................... __ .. __ ... _...... _.. _.

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Remains to be shipped-see reverse for details.

Interment at..........D1.c.e...C.eme.t .e.r,y ............................................................................................................... .. Lot No.........................._........... __ .... Seetion No..._____ .. ___............................... Grave No .............................................. . Ramarks .....................

6.J9-....(.J.$....ga.;...........cD.ppe.r.:tOne... n9.....shading ................................., roseh e1ge venus a tin- p ipe organ panel

::::::::::::::::::::::::::::::::::::::::::::s;~:i~fi~:i~LQ.~~.§~.~.~.::·.·Mi.g:~::::Q?::;::::::::::::::::::::::::::::::::::::::: ....... FORM

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aUPERIOR F U NERAL BU"PLY CORP •• CLEVELAND, ·OHIO.

............ Ambulance .............................................. ..

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Funeral Coach ............................................ . Passenger Cars ____ .... ______........................... . P a11 Bearers ' S ervlce . ......................... __ .... . .. .......... Transferring Body.................................. .. n

• • • • __ • • • •

Opening of Grave..................................... . Cemetery Charges ................................... .

~~:c. ·~;~~~;~~~~;~~::::: : : : : : : : : : : :: : :

Shipping Charges ...... __ ........ _.................. Clergynlan ..................................... . _......... _/ Singers $................ Organist $:

_.......... Cash Adva:c~.i

_......... I .::h..~4/.. .....

=:=::~:::\ :::::::::: ..........

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~64 Date..NQY.~IDJ,).!Zr.._.;G->-.m 9

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FUNERAL RECORD OF No•... _..___ .._.._.____

Yearly No ...._.._.. _..

l?!±.._......_...

Name. ...•.. _........_.... _.._.M.inn.1e....Sml.th ............. ~ .._.. _.........._..................................... sex. ..f..~ma.+..e......... Addnlss ................................._.QQmmer.c.a•.... Q.klal.l.9..ma................................................................................ COunty... _.................._.........._.. _...Township....... _........•... _... :.......................Phone No ............................ _.............. .

Where Born............._Ba..cr.y... _C.QUntl".•.....M1.s..§Ql-lt'.;), .... _................. Race....... ~!h.t1;.~.........................

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Date of Birth..ll".lD.-:=.l /3/3.Q ........_............................Ag•............. _.......................................................... _...... . 11-10-1881 Old Am. (Years) (Months) (Days)

How Long Resident in Community...................................... __ ..._. __ ..... __ .................. ___.. __ ........ __ ................................. . Single..........._...........Married. .......................Wldowed ...W.;),Q,9.lY.!'!.!J;livorced...................... Child............................ Husband, Wife or Child 01.....•••...••••..••••..•..•••....••..........•..•...•....•.••... _.•...••. _................................................................. Address....... _...._........ _.._.. __.._...._...... _......................................................................................................................... Closest Relative. __ ...Thalma._.P.aslK\l_1i.y. ........................J..ddress......Qg.~ .~ F..5?!?J.....~_lS.~.?J.l.'?!!!.~

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Father's Name......!l.ez.z...Harher.L........................_.. _..," ..Birlhplace... _............................ _........................... Mother's Maiden Name.......Mar.gar.!'l..t...............................BirthpIace... _........................................................ . Cause of Death................................. _............................................Contributory......................................................... . Date of Death..._..N.9..Y.§IDp..~.r...

.1.:I......:),9.5..9....................Hour............................~.:.. )~.:.............................

Pl.ce of De.th......Q.Q.mm.~r..Q.e.~.... Q.l5,[email protected].<'i............... .How Long Ill ?.................................................... . Physician.......................................................................................... Address __ ..___ ...__ ...... __ ............................................. . Occupation of Deceased........ .nD.US.elll.1i'.e ......................... Social Security No .............................................. Name of Employer........................................... _..................................................... ~ ..................................................... . Addr ess ............................................................................................................................................................................. .

Charge to.............In.s.ur.an.c.e...........................................:... _.Address ................................................................... Order Given By........M.:b)}n.;l...~.....S..f!!.;\..:t.h................................Address................................................................. .

J 9.5..9.................Time.................. ?... :E'..~.~..~ ................................... Place of Funeral Servlce............. ..Exe.t.e.);'_...8.a;pJ,J,.§.i!. ... 9.h.Y.,I'9.h............................................................. Date of Funeral....... N.O.Y..eIDD.e.:r.....2.Q•....

Clergyman ..Y..anZand.t ....a.n9.....M9.Q.Q.rm)..5?K .............. Ca11 for? .............................................................._

C.sket

_

(Style) (No.) Outside Case or v.,R,"ol..' ............................... --!-..... Emb.lming Body ...................................... 1.............. 1 Professional Service .... · ................ · .... ·....··1 ...... ·· ·..··1 .. .......... 1 Hair "lJrllSSElr.. ·•• .. •...... •·•••··•·••· .. ·• ...... .... •• .. ···I······· .... ·.. I ............ Suit or Dress ............................................. . --!-.... . ............ Shirt, Collar, Tm;" ...................................... --!-.............. I Shoes $...................... Hose S~_........................I..••••••••••••• I Underclothes ............................................ 1............... 1 ...... Door Spray ................................................ 1.............. 1...... Gloves $.................... Ch.irs ..................... S I ...... Flowers $.................. P.lms .................. $ Cremation .................................................... -1... _.....·· ..·1..·..· Newspaper Notices ..................................... 1.............. 1... _. Telephone and Telegraph....... _...... _....... I............... I...... Ambulance ................................................ 1.............. 1.... ..

+...........

············1

+............

+ ............ + .............+ ....

Funeral Coach············································I··· ............ 1.... .. P assenger Cars·········································· I···· .. ··...... 1.... .. _...... ..... 1 Pall Bearers'· Service································I .. ·..····· .._.I .... .. ............ Transferri.n g Body.................................... I.............. I...... Opening of ~!ave ...................................... I............ I...... Cemetery Charges····································I ......·······.1 ...... Lot ................................................................... 1.......... ·····1·.. ··· Misc. Transporta tion ................................ I.... _......... I..... . Shipping Charges .................................... 1.............. 1..... . Clergyman .............................................. _.1 ...... ··1······ Singers $................Organist $.................. 1.... .......... 1...... _.......... Cash Advanced·································_·······I···· .......... 1•••••• _ ····· .. 1 .. ·· ····· .. · .. · .. ·· .. · .. .... · .... ·· ····· ·· .. ·· .. · .. ···· .... · .. ········1....

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Address......................................... _...................... _ .............................._._................................................................_.._.

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Total Amount.................................. II----1 __

Remains to be shipped-see reverse for details.

Interment at......._... ..! e-J).l.e.~l.Q.o.!L.Q.~.m.$. .t . ~!;X .........................:................................................................... Lot No ................................_........... Section No ..............._.......................... ,.Grave No .............................................. . Ramarks .....................li).l;''OI-l~..,....r.lD.~ .a.~ading. ....st.e.e l

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Information Given To: 0 Relatives 0 Musicians

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Lodges Pall Bearers

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Death Certificate Payment Arranged

o

o

Attended To:

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Clergyman Singers

Pennit Bill Rendered

natellI.Qy.e.mb.e.r. ....l9.....J,.95.9

..

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CHECK EACH ITEM AS COMPLETED

FUNERAL RECORD OF

\

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No..........................._ ..__

...4y No...............f:.?5..................

Ca!~t,;;e~ault..@2.~~:)...........

Name. ..........................................J .e.l1I.e.l1....l:.....1ie.sJ'........................ ________ .____ ......_._.____ ..sex._ .... f .e.mal.e.....

Outside

Addr.................. ___ .... _..._. __..... _._.... _....C.aa.sy..ll.le.•.. __ Ml.§.!).Q.~.+.:j, ... ___ ...__.. _.................. _............._.................. .

Embalming Body .................................. ..

COunty_. __....•Bar.r.y....................ToWDship_ .. _.._...........................................Phone No................ ___ ......._._..... _.. _..... .

wbl_:te... _.. __ ._.. _.............. Where Born................llla.lnut... G.r.Qll.e., .... M.i£lso.uri ......................Race.... _ (

Casket&.... S.e.rllic.e.s ......................_._.

Date of Birth. ......'3.e.p.t.em.her.... l},····~~~·· ..·..·......(1Z~~j·

:::::::::::1::!es~~e::~r~..,=i.C~.::::::::::::::::::::::::::::::: Suit or Dress .......................................... .. Shirt, Collar, Tie .....................................! Shoes $......................Hose $.....................1 Underclothes .......................................... .. Door Spray .................... ___....................... ..

. ·. ·····Ud~;;th~) ..·....·..··(D;;-y~)·.

How Long Resident in Community.............................................:_................. _...... _..................... ___________... __ ..__ .......... .

Single........................Married. __ .ma:r.:r..;!&Widowed............... _....... Divorced...................... Child .................. _.........

Glove. ; .........._.........Chairs $................... . Flowers $..................Palms $..................

Hu.band, Wife or Child of....__....•........ _...... -.•.M.....Re.s.s ................................................................................... Addres...................._ .............._ ..................................... ~.s..s..'!..U.1..~.1.' .. I!.1.j,.!l.!9.CJ..Ll.~.i. ........_...................... .... Clos .. t R.lativ._.......... ..... • ... H.e.s.s. ......._.............. _..... _.....Addres •....G.as.s.::.il.le.•.... Ml s.s.Qu.r.l. Father's Nam• .......Eph ...Edw.ar.ds.....................................l!irthjllace...... _....................................... _............... Mother'. Maiden Name.MaldQ.... J)Jli\n~.~!}.Eb~..+.p............ Birthplace.~ ......................................................... .. Cause of Death ............................................... __ .. ___________ . _____ ...........Contributory....... __ .....::...... __ .... __ ... __...................... .

~:::,~:.~~n~:a~h:::::: : : : : : : : : : : : : : : : : : : :1

Date of Death....N9.ye_ID.bfW...1.9.•... _.J,9.5.9......................Hour .....:........... J ;..3.Q.....A.,....M.,...................... Place of Death....s.t .......J..Qb.'..a....... S.!l.f.J.,g.A ......................How Long Ill? ....................................... _.......... _.. Physician ....... D.r.._... Lang.S.t.O.n.............. _............................. Address .......Sl?:r.tng;t.l..e.ld., .. Occupation of Deceased............ hQu.s.e.Vl1.f.e .....................Social Security No ...f.:.'l':L:::: ... ':f:.Q:,:: ...207 Name of Employer..................................................................................................~: .....~ .... ~.-4,)

Lot ............................... _............................ ..

9..

Cremation ...................... _.......................... . Newspaper Notices .... _... _.........................

Telephone and Telegraph ...................... ..

Passenger Cars .......................................... Pall Bearers' Service ....... _....................... _ Transferring Body.... _............................. .. Opening of Grave..................................... . Cemetery Charges ....................................

.lw.•.."""

m.:..lll..,..

Misc. Transportation ........................ _...... . Shipping Charges ................................... . Clergyman .............................................. .. Singers $................Organist $................ . Cash Advanced ......................................... .

Address ............................................................................................................................................................................. ..

Charge to......M•.lil-. ...Re-3.s-................................................... ...Address ................................................................. .. Order Given By.._.... l !...... .. .... H.e.s.S .. _and. .. f .amily...Address......._.......................................................... Date ofFuneraL.......~L¥~3llio@,r.....2 ,lT-...J~9!~~........"..... j:ime.......................2 ... ~ .• ~~.- ........ -..................... .. Place of Funeral Selmc:..........~:~u:aJ, ... J~.a,J;l .•II.J..!;U,... :~!JJ.ll;:.Q,[l .. _._ ...::.............................................................. Clergyman ........... Cha!;l
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'l'otal Amount................................. . Remains to be shipped-see reverse for details.

Interment at... .......

o.a.l;;...H.l.l.~ ...C.
Lot No .............................................Section No ............... _..........: .......~ ......... Grave No ............................................. ..

Ramarks .................... _..2.;?Do:1-....Ir.i.s....Silll.er._... sh8..d.e.Q, .......s.t.e.eL.i. .. cb................................. ..

Information Given To:

o o

Lodge.

0 Relatives

Pall Bearers

0 Musicians

o

Death Certificate

............................................L.t ......EJ..e.sh_.Q.r..d.e....9.b.J.!)&.J?hSlI'J.g,@....w.~.th... ge..\1:t. ~I' ........ n ..........................................£?-Y...J!§gDg~.j,.9: ....~.r..9:~....c.~.~~~.:::.... ~.~.Ci.e.... Ea.:!1..11....t:L.e...s.l:l ... :L.~?.e.rty ...............................................G.onner.8.111.ll.e_.. _C.a.Ske.:t.....c..9..,................................ .................................. . FORM s a30 S U PERIOR FUNERA L S U PPLY CORP • • CLEVELAN D , OH I O.

Attended To: Pl'lvment Al'l'al1 ~e d

o

o

o

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Clergyman Singers

Permit Bill Rendered

366 Date. .....))lQ:\L.e.mb.e.Ll9.,.....1.959

.

C::.:K&~~m:.~.~. =:~.~~

FUNERAL RECORD OF

Jg.§...............

No........................_ .._ _

Yearly No ................

Name. .............................. _ •.C.lar.a ...EJ.1sm....!!lQ.:r..1i9..P.: ..............................................Sex.. .f.~.ID.\;J.!L ...... Addres ............................................Ell.!'.e.ka...S.p.I·.l.nKf;l~.... A;r:~.(j..P.:.s..(j..§...................................................... COunty.........C.a.:r..:r.Q.l 1.............Township..................................................Phone No ............................................ . Where Born......................MiS.s.Q)J.:r..;\,......................... _ ........~ ........................Race...........l,IIhLt.e.....................

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Date of Birtb......A
S.•....l.S.5.6.........................Age................ l 3............................................................. (Years)

(Months)

(Days)

How Long Resident in COmmunity........................................ __.................................._... _......_.................... ___ ._ ..._.. ____ _ Single........................Married. ....................... Widowed ... ~.;t..
int.Q....C.aY.J.!l..............Birthplace.~........................:................................... Name..Ba.r.b.ar.a ...E1J.~.D.... Q.(!r.9A.\Bfrthplace.. ;.......................................................... .

Father'. Name....c.o.f...f.e.e....c.l

Mother's Maiden Cause of Death............................... ________ ...... ___ .........................__ ...Contributory __ ........... ___ .......................................... Date of Death..l\lQY..e.mb..e.:r....1.9..•....

1.9..5.2........:....:..........Hour..........:..11.:.4.5....P.•.r .•............................

Place of Death.... Car.l'o.ll ...CQ.unty..•....!i.9..!?1?+.:1i.i?.-. £ow L~~g III ?................., ..................................• Phy.ician ........Dr.......C.......F.•....S.m.l..t h ................................. Address .... Cas.B.y..1.1le..•....M1.f;lJ'.Q1\:rJ. Occupation of Deceased...... ho.usel.~.if.e ........................... Soci.1 Security No .............................................. Name of Employer ........................................... _............................................ _.~_._._ ............................ __..__ ............ _........ . Address......................... __ .__ ...................................................... _.................................................__ .............. __ ...... _...... __...... .

Charge to.................

Mr.B.•... J ....... A.•....Q.I..K~n~..................Address........... ~.r..(3.1t.I:I:....!'.p..r..l.:z:t!!i.~L ...p':.l'k •

Order Given By........ __ ..........I_I.................................................... _...Address ................._............... __ ....... _.................... .

Date of Funeral .........NQ.y.~.!!!p..~.r. ...

?3..•....J.9..5.9...............Time.......... J.9:...A.!.....M.!.....................................

Place of Funeral Service.............Chr.1E:t.lAn...Qh1l:r..QD.:::)i;:\l.r..e.~.~.... !3.p..r..~.Il:g.!l.!. ....

Ar..lI:..~...........

(Style) (No.) Outside Case or Vault .............................. . Embalming Body .................................... . ············1Professional Service ................................ . ···.·· ···· . . 1 Hah' Dresser.............................................. . . ........... 1 Suit or Dress ............................................ . Shirt, Collar, Tie ...................................... . Shoes $...................... Hose $...................... , Underclothes ............................................ ]1 Door Spray ................................................ Gloves $.................... Chairs $.................... Flowers $..................Palms $.................. Cremation .................................................. . Newspaper Notices .................................. . Telephone and Telegraph. ....................... . Ambulance ............................................... . Fun eral Coa ch ........................................... . Passenger Cars ......................................... . Pall Bearers' Service................................ . Transferring Body.................................... ~ Opening of Grave............................... _..... . Cemetel'Y Charg(!s ................................... . Lot ............................................................. . Misc. Trn.nspor ta tion .............................. .. Shipping Charges .................................... . Clergyman ................................................ . Singers $................Organist $................ .. Cash Advanced ........................................ ..

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:~t:t.;:::~:~:~:::::::: : : : : : : : : : : : : : : : : : 1

Clergyman......... _..............__ .... _.......... _......................................... Call for? .............................................................._

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Total Amount. ................................. lli ___ , Remains to be shipped-see reverse for details.

.. ..':::.: ':........=~

Interment at..................(~r..e.fm,l.a.W.!LQ.ftm:e..~'.~.j~y.:::.~!.P..r..1. .JC!.e~.r...~.,:.:':''!:.! . ....l~::~ '~.':'

Lot No ............................................. Section No ............................................ Grave No .............................................. . Ram ..·ks .................... gx.ay. ....sh.aae.d ...a.UY..(l.:r..:-..I?t~e.J

.....f:1..e..~.:J,e..I'....................................................

......................... ........U?;l:l.t .... i7.nQ, ...Q.g,E~... Kt:.~y.....C?y.e..p..~ ....~.r1:~.El.r.~.?E..................................

..............................................Qg.m}.e..t.:§.y..P.~~....g.~.~..k..~.~.... ~.~.'....................... ......................................... F ORM 15235 SUPERIOR FUNERAL SUPPl.Y CORP •• CLEVELAND, OH I O.

Information Given To: Relatives 0 Musicians

o

o

Pall Bearers

o o

Death Cer tificat e Payment Arranged

Attended To :

o o o o

Clergyman Singers

Permit BUJ Rendered

Insurance ......................................................................................... .

Date. ......))JOlC.€.mb.e.r._.2.l,_..J..;J

59

...

.

CHECK EACH ITEM AS COMPLE'I

uJQ..

FUNERAL RECORD OF

No........ _.. _......_..___. _ _

Yearly No ...._.....

12J........_......_...

en dale.... Daw.sQn..Hat.fie.ld ...................................sex. ...f.ema.le ....... Addre.s........._........ _................ Gall.I;ly..i.ll.e.. ....Mia.e.Q .ll.;r..i............................................................................ COunty...... li)a.PP;,<.......__..........Townsbip... FJ.a.t .c ae.ek ..................Phone No ........................................... .. Where Born. ............Nfly..ada.. ....Mls..s.Q.l,rr..l. ........_ .................................Race.............. .1~h.;!..t.fL ............ .. Date of Birth..........Q.c.t.o.b.er...l E\85......................... Age................ .7.l ...... ~.................................................. .. Name. ...... _...................Gl

(

(Years)

(Months)

(Days)

How Long Resident in COmmunity............ ___. _____ .......... ___ ........................ _.. _........ __................ _....... _........ __.______ . ___ ........ Single....................... .Married.m1?,r..r.;!,~.gWidowed ....................... Divorced...................... Child.......................... .. H usband. Wife or Child oL ...................... A.. ....J......Hat.f.ield.................................................................... . Addr.s . ......................._.._._._.._...._......_ ...............Gaa.G.vi lle.. ...

ILQ..............................................................

Closest Relative........la.\,\,\lba.nd...............................................Address........................................ _ ..................... .. Fatber's Name.......... AnQ,.: r.!l.YI....J.:-'--..p.Iil.~U?Q.IL .... _.._.....Birtbplace ............................................................ ..

Mother's Maiden Name... _b.1Jg.~.....F..~.~~.~.:J,:J, .............. ::::Birthpl~ce ............................................................ .. Cause of Death................ __ . _________ ................. __ ........ __ .. ___ .................Contributory................................__ ........................ Date of Deatb ... .NO.y..emhfl.r. ...2.l... .... l95.9. .................... .nour... _.......... J ...l'.... M................ _.................._. P lace of Deatb......B.ur.ge....H.Q.6.p..t.t./l.l:::.s.P.f..l .d .......lIow Long Ill? ................................................... .. Physici.n ....... D.r. ..... Lang.s.t.o.n .................................... ,...... Address ..........Sp.~.1ngf.le.ld . ....Mo........ Occupation of D.ceased..hO.uSe'".1.t'.e ............._................ Social Security No ......iJ:9.6."'iJ:2..".665!±..... Name of Employer..... __.____ . ____ .. ___ .................... __ .. __....... _................................. __ ........ ;...................... __ ............. __ ........... . Address ___ ........................................_.................................................................. ___ .................................. ___.....______ ... _... ___.,

Charge to ... A. ...J ...... Hat.f.le~d ........................................Address.:........C.Iil..s.Sy.l1.le..,...JIlQ................

....J ......H.at.f.ie.ld ........................Address................. _............................................... Date of FuneraL .....tiQ_y..e.JIll>..<;lr.....?!±"' ... J.95.9................Tim................................ J... J'.,J4.,.................... .. Place of Funeral Service..._...Q!J,J;lI:e..: r..!..a [email protected] ......................................................................................

Order Given By....... A

Clergyman ........ B.~.y..,

.....®Xm.9.!.l.g..J?J~g:l!:......................Cal1

Casket

(Style) (No.) Outside Case or Vault ...... _______ ...__ ... ___ ...... Embalming Body .. ____ ............................ __ Professional Service .______ ..... _.................. . ........_-_. J Hair Dresser.. __........................................ . ............ Suit or Dress ........... s.:\iQle. ................. Shirt, Collar, Tie ...................................... Shoes $......................Hose $.................... .. Underclothes .___....................................... . Door Spr ay .............................................. . Gloves $.................... Chairs $.................. .. Flowers $..................Palms $.................. Cremation ..................................................1 Newspaper Notices ................................. . Telephone and Telegraph....................... . Ambulance ............................................... . Funeral Coach ........................................... .

Passenger Cars ......................................... . . ........... Pall BcareJ.'s' Service............................... . ............ Transferring Body................................... . Opening of Grave ..................................... . Cemeter y Charges ................................... . Lot ............................................................. . Misc. Transport ation................................ Shipping Char ges .................................. .. Clerg yman ............___ ......._...................... . Sing ers $.......:L.... Organist $....;;C....... . Cash Advanced..........................................

..8al.e.s.... Tax. ...................................... . .....................................................................

for? .............................................................._

·........ ·~·~·~i. ·~~~~~~::~::::::::::: ::::~::: :::::::::::I

Address.................Q.g,.\'l.\'l.y..:i,JJ.~...... MJ.fu?Q..W;·.:i,.................:._...::....:.......... ..

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Remains to be shipped- see reverse for details.

Interment at.......... Mt

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... Ro.pe... D.em.e.ter.y."Wehh ...C.i:ty.. .... IB.s.Q."

Lot No .............................................Section No ......•........ _............................ Grave No .... .\ Ramark ...................... 1.~_Q!....~.~...Q.9.nn.~r.f!.~3-.:L...1l!~~x..~;;.f/!.~~:l!~,

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.....................................R.'"';r.)L....B.;r.Qn2.e...D Q....sb.a.dlng...................................... ~ ............................... ...........................................Q,3-!'~r.Q§..~....P..~.;j,K@... Sg:~p..~...)..n~.~.!~\t.9.:r................................. .........

Connersville Casket Co.

FORM 5235 S U PERIO R FUNERAL SUPP L Y CORP., CLI!YI!:LAND. OHIO.

. "'.iJ.a\!.J.t."'.S.fl;r..Y.;!..Q..~.S........

o

Lodges Pall Bear ers

Information Given To: 0 Relatives 0 Musicians

Death Certificate n PSl,rm.:>Tlt. A'I'rRl1aed

Attended To :

o o o o

Clergyman Singers

Permit Bill Rendered

(Boone) Datell!'O.1l.emb.e.r.... 2.1,...~

CHECK EACH ITEM AS OOMPLEI'ED

FUNERAL RECORD QF Yearly No ...._......_1.2.8..... _......_._

Casket ........................................................ $...~ .............

Name.·····.-.·......- ............- .... -....- .....We.l"fie.l"......P..r.\l.J.:tt.............................................. sex......m.a.:Lfl...........

Outside ........... ................... . Embalming Body ...................................................... .. ............ J Professional Service .............................................. .... .. .. .......... J Hair Dresser.............................................. ................... . Suit or Dress ............................................ ................... . Shirt, Collar, Tie...................................... .................... Shoes $...................... Hose $.................................... ...... Underclothes .......................................................... ..... . Door Spray ................................................ .............. .... .. Gloves $.................... Chairs $....................................... . Flowers ~.................. Palms $.................. ....:......... ...... Cremation ..................................................... _............... Newspaper Notices ............................._... ..._............_. Telephone and Telegraph........................... _............... Ambulance ................................................ .............. ..... . Funeral Coach ............................................... _............. .. Passenger Cars ............................................................ .. Pall Bearers' Service .................................................. .. Tran sferring Body .................................................. ..... . Opening of Grave ........................................................ .. Cemetery Charges ....................................................... . Lot .................................................................................. Misc. Transportation ................................................. _. Shipping Charges .................................................. .... .. Clergyman ................................................ .................. .. Singer s $................ Organist $.................................... .. Cash Advanced ............................................................ ..

No•... _.. _.._...... ____. _

Address ................................._........_.._.... _.F.*ir.:\f.ie.~L7.....Mi.s.so.u.t'.1. ........................................................... COunty... _.Ne.'!!.tO'tl.._......_.._...ToWDship....... _........•..._...........................Phone No ............................_............... Where Born............._.~~..~.~ .?t..~~~.~.~?..::!~ ....._.._...._...........................Race............................................... .

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Date of Birth ..... Ap.I'.;tL.23.•....

J.6.9.3......................Age............•....9..6............................................................ (Years)

(Months)

(Days)

How Long Resident in Community....................................................................... __ .. __. ___ ....................... __ ....... ___ .......... Single........... _...........Married.m"'.r.:r.J51.9. Widowed....................... Divorced...................... Child ........................... . Husband, Wife or Child of....._..................C.r.Y..s.:tal. ...P..ear.l...Da:v..en. .Qr..t ....P.r..ui.t.t .................. Addres•............. _.. _...._.. _..__ .._ ... _.._.._................... F.!i\.J.ry..~.~.w. •...J'(1j,:Ul.Q.liI'.J ........................................... . Closest Relative....... _.................................... _............................. ..Address .................................................................. Father's N ame. ................ _...._............................................_.._.... .Birthplace... _........................................................ . Mother's Maiden Name. ______......................................................__ .Birthplace~ ..______ .__ .. __ ._.... _..................................... Cause of Death ............. _................................................................COntributory.......................................................... Date of Death... _..N.Q.1/:amb.e.r.... 2.1, .....1 9;i.9...................Hour ......................................................................... Place of Death ...... Car.dl!!.e.ll ... liQ.sp.i.tal ..................llow Long III ?.................................................... . Physician .......................................................................................... Address ................................................................. . Occupation of Deceased. .............................................................. Social Security No .............................................. Name of Employer........................................... _........................................................................................................... . Address ............................................................................................................................................................................. . Charge to ....................................................................................... _Address............................................. _.................... Order Given By......................................................................... _...Address ..................................................................

Date of Funeral... ....b!o:\f.emb.e.r. ... 2,p.T.... l

9.;;.fi!................Time ...............2..l' ... !.L•.......................................

Place of Funeral Service....... Mc.Q,u.e.e.n.!..Il.._Gha:p.al......................:.......................................................... -. Clergyman [email protected]..•.....I ..r_.L •....)'3.
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C.J~~;etault(l).~~:)

=~==:.:I:.:. .: .::::.:.:: .:.:: : : : : : : : : .: . : ::.:.:. . :::.::.1::::::::::::: :::::: Total Amount.................................. - - - -_

Remains to be shipped-see reverse for details.

Interment at................._........ _D.ic..e ... .G.S.me..:t. .r.y............................................................................................... Lot No ............................................. Section No ..............._............................ Grave No ............................................... Ramarks ......................._................................................................................................................................................... .

Information Given To: D Lodges Pall Bearers

o

o

Death Certificate D Payment Arranged

o

o

o o

Relatives Musicians

Attended To :

o o

Clergyman Singers

Permit Bill Rendered

Insurance .......................................................................................... FORM 82 315 S U PERIOR FUNERAL SUPPLY CORP •• CLBVI!LAHD, OHIO.

• ... ...... .................................. ........... ... ...................................... .......... ..

Date. ...NO'lT..e.mher..... 2J.......l959

.,

361

.. , ." . '.'

CHECK EACH ITEM AS COMPLETED

FUNERAL RECORD OF '

No...................._ ......_ _

Yearly No........_ ...

.1.2.fI.................

Cask.t .....&....!>.e.;r.yJ.Q.e..§ ...................

Ca~:~;etault ,&r~:)............

Name. ..................................V/..l.lliam ... D......Br.o.vm ....................................................... sex. ......mab.e...........

Outside

Address ........................... .l.l.Q.Q..J!la.l.n... S.:t.l:e.§:t..,........... Q.MElY.U.1.f?,.....MJfl.~,'?.!:!.:.::;\......................

Embalming Body ._____ ................ __..___ ._____ . Professional Service .............. __ ............... .

County...... B.ar.r.y.......................Township ................._................................Phone No ............................................ . Where BOnL............Gr.!UillJlJ,l,J,§.,.....

::::::::::::1~:i~ o~r;;::s:·:::::::::::::::::: ::::::::::::::::::::::::::

U..Ur.t<2J.1!................................Race...............\'Il:l.~.~.E,l .......... ......

............ Shirt, §l.qijll!X)f~...9..+.-.~.?,!:!,;\..!!:g ....s..~ Shoes $...................... Hose $.................... ..

Date of Birtb. ..J..aJl.J.l.\\.I!¥-...2.6, ....J.$-l.Q................ ..Age.................6.9............... ,......... ,.................................. (Years) (Months) (Days) How Long Resident in Communl'ty................•..•..•••........•..................: ... _.............. -..................................... -.............. "" o .,",J° ,.;(·vo rced................... ,,' Ch'ld S ingle........................Marn'e'~.......... .... ........ . Wid owe d....'"'i ". '"" .. "..... 1 ...................'" ...... . H us ban, d Wif• or CJilld of.........Fount in EPa "ro"'n . . .a ... ....b. .............. '-'................................................................... " .. "

Underclothes ............................. -............ _Door Spray ............................................... . Gloves , .................... Chairs .................. .. Fl . P I$. owers ................... a IDS ~....... .......... .

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Address ........................... __............................."".eQ.e.g.?.~.................................................."........................................ Cremation .............................. " ....." .......... . Closeat Relativ•. Lenn.e.th .. B.r.o.wn................................Address ......... ,.O.g.?.§.yJ..l;\& ...... M9..:........... Newspap2r Notices .. " ................ "........... . Father's Nam.........l'lnL....Reruie.r..aQn ...Br.o.w.o...........Birthplace............................................................... Telephone and T.legraph.. " .. ,... ,...... " ... .. Mother's Maiden Name........ v·Q·:v:-s-m,w@r.····G;:·t··,····· -j) ~;J-:;r """"" """ our......... .:-~... ....... .......,.{.•.i.:.............. ... P 11 B ' S '

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: lac8. ~f Death·D~.ho.me........:·...... ·~idii~ "'.HOW Long III b'~'s 's ;;:iIii~7·"'Mi"s·iio·U':i hyslcl.n ........... ........Y. ...... E ......G...."...............K..........."... ",Address ................." ..... " ...... ,", ... " ........,,,.,,"",, .. ,,'

earers

............ Transferring

ervice .............................. ..

Body.. ".... " ......." ...... " .... . Opening of Gr.v......... ".,,, ................ ,,, .....

Occupation of Deceased.. ....................,.......................................... Social Security No ............................................. .

Cemetery Charges ................................... .

Name of Employer ........................................... _... _...................................................................................................... .

Lot ..............".,., .. ,"" ............ ,......................

Address ............................................................................................................................................................................ ..

Misc. Tl·ansportation ............................... . Shipping Charges ................................... .

Charge to....... Ke.nne.th ...B.~QYi.n.... "....... "..."............:........Address ........g.":.s..s..v..~}.~.t3.!. .....~!() ~ Order Given By......t'.a rn.i.ly......................... ,........................... Address.............................................. ,.. " ....... ,...... . Date ofFu:nerM..........~~~f. .......!.!~.~:~l~,~l ..............".. jrime.............................. " ........................... . Place of F uneral ::;elrvi"e..............l";.\;\.L:Ir.e,r. . ~ .s,....Li!:W9.p.tl••J... ".. "".......,, ...... : .................................. , Clergyman......Re.ll.......fL....W ......Ohane.Y............................ CalI for '{ .........................." "T

.. ..............

~;Iif:I~~;~~~:J - ..·....·1 .... ····.... "·"··,,· .... ,, ..··, ....·,,.. ·,,···..·· ,········ __ ...... 1 .. ............. ... ..... .. . , .... " ............... " .......... , ......

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Total Amount.. .......... ,'" .............., Remains to be shipped--see reverse for details.

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Information Given To:

Inrermenta', ..............,~A .. ~. ~~~ ... ~,.~lz . N,~,~ .,'." ............................................... .

Lot No ............................................. Section No ............... _............................ Grave

NO'.•" .. ,;:" ......... :" .. " ................ , ,, .. .

Ramarks .......................... #6.3.Q....l.S.... g.a..,."..Qg.P..P. .~T:t9.!!:§l ....l1.Q" ..EJl:l.~.
....p..~.:r::t:E,l.~,~,~,().!l ..".. "........................................RQJl.e.Qf?.:),g~_ ...I!..~P..~!,l ...EI§.:t..~!l.::.I'). i.P..t3... g:r:.~.~::: ....p.."::::~.~ ........". ....".".. ""......"...........................ap.r.l.ngf.;i..e..lg,...g..q,.§.~.~.j;....M.r g.:....9.g.. ~........ ",'................. "................

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Lodges

0 Relatives

Pall Bearers

0 Musicians

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Death Certificate Payment Arranged

Attended To:

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Clergyman Singers

Permit Bill Rendered

Insurance..........................................................................................

F O RM !!28!! S UPERIOR FUNERAL SUPPL Y CORP •• CL&V II:L.AND . OHIO.

1- __

Date..J)lOlr.emb.er..2.7.• _.1.95.9

FUNERAL RECORD OF

CHEC:

130 Yearly No .... _.. c .._ .•l.?jI..._......_...

N 0 ........_ .._ •• _ .. __

ITEM AS COMPLETED

(No.)

Address......._....B.l.1.a.$....B.i1y.fln...Bg.~.!;.... !:!.CJ.III~.::-}1.~..~ .... Y..:']E!1.().l1,!..... !'Jl.~~.~.().ll.:.~

E mbalming Body

........................

::::::::::::II ~air

............

J .$..1?9.................Age................. J.~................................................ _.......

Dat. of Birth.....Q.Q.j;;.Q.Q.~.r. ....?9......

(Year s)

(Months)

(Days)

How Long Resident in Community.............:thr.e.e .... y..~.ar..~............................................................................. Single........................Married. .......................Widowed ... ilIl.dol!!.edJivorced...................... Child........................... . Husband, Wife or Child of..................................•............................ _...................................... _.....•............................. Address............. _............ _...._................ _......................................................................................................................... Closest Relative._.G4r..ti e... E.cll!J.ar..ds. ............................Address ...J..~.Qf:i.!:l.!>.l .... ~.:l,~.s.c::.~.J:::l:

........

Father's Nam•......J ..•. _.R-.._.E.s.s.ar.y........................._.. _.....Birthplace... _........................................................ . Mother's Maiden Name...-Mildr.ed ... B.r.ans.:t.e.:t.t .e .lJlirthplace. .. _......................................................... Cause of Death......__ .......__................ _............................................Contributory___......... ___...........................................

J.9..5.9. ...............Hour........... ~ ..........6...l'..ll..........._.....................

_..........

Place of Death...B-l.;\,fl-ll...Ha:v:.en...Re.s.t ... Hom.e........ lIow Long Ill? ..................................................... Physician ..................................... __................................................... Address .................................................................. .

............

Dat. of Death..._..... NQy..fl.mP..~.r.... g.7..'---..

Occupation of Deceased............................................................... Social Security No ............................................. . Name of Employer........................................... _.............................................:............................................................. . Address ............................................................................................................................................................................. .

Charg. to............. G-er.tle....EdlNar.u.S............................. _.Address·············J€fl-ll;,ins.j··.· ~;j,&-llG.Uv..l Order Given By........ G.g.r.tlfl ... EQ,~I.ar.Q..!L ................. _...Address............ .J~nkinl>,.... Mis.£D.uri Date of FuneraL.. N.o.:v..ernb.er.... .).Q.~ ... J.95.9. ..................Time ...................... :P...~.lI!.: Place of Funeral Service... _...J .Qn.e.S....Q.c_b.QQ1 ..HQ~.§.~.........................................................................._. Clergyman ......... _.............. __ ................ _.........................................Ca11 for? ................................................................

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rofessional Service Dresser. suit or Dress ............................................ shirt, Collar, Tie. shoes ~......._.............Hose ~ U nderclothes D oor Spray Gloves $.................... Chairs !l. F lowers $.................. Palms s. Crarnation N ewspaper Notices elephone and A mbulance ... Funeral Coach . P assenger Cl Pall Bearers' .. . Tr ansferring Bodv_ Opening of r., Cemetery L ot .. .................. ,;, Mi::;c. Shipping Charges Clergyman Singers $................ Organist $. Cash A

............,T ............ ............

................................

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:lothimr

outside Case

Wher. Born............._.......8.:to.n.e__C.o.unty.•..J,U.a:e.Q),l.r..:!,.................Race ..........1Yl})..~.~......................

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Name._._._........_............_........__ .M.1nnl~....~.~lJ...A§h.~.~.......;................................. s.-,... female ........ . COunty.....laYl.r:e.n.QJL .._.. _...Township......._............_...........................Phone N 0 •. ••••... •......•. ...•...... _ .•...... . .....•

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Casket

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Total Remains to be shipped-see reverse for details.

Interment Lot No ............................................. Section No ..............._............................ Grave

..........................................yi.Uit..fl.....(lB.t .ln.. J,y!.;\..U ....±D.~.~.r..~.().:r:............ .............. ..... ........................ ...............: ................ J?!?!.!::Y!.0.;_...Q.?:.~):c.e..E. ...R~.€\.:....g.~..:..................................................................

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Lodges D Pall Bearers

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FORM l5.2 l!1l1 SUPERIOR FUNERAL SUPPLY CORP. , CLEYELAND, OHIO.

Death Certificate Payment Arran~ed

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Information Given To: Relatives Musicians

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Attended To:

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Clergyman Singers

Permit Bill Rendered

371 Data ......

QY..elub.e r.__3.Q._..l959 FUNERAL RECORD OF '

CHECK EACH ITEM AS COMPLETED

Yearly

No•......._.._......_.._____

No_ .._..... l}l ......._......_...

Name. .._.._.................._.. __ ..NaIlQy.....L.1.fl.a ... Q.r.:r.... _..................................................... Sex. ........ .f.\1m.a.~.:J,. Address ....... __ ...................... _.....J.e.nkina.~ .. J 1a.SQ.ll.r..l................................................................................ COunty......Bar.r.y....._.._.._.._... Township ......._....MQIl.Q.nal.Q, ...........Phone No ............................................. Where Born..........~.I?;;:.rX....Q2.ldny.y..,.....M.~.§..i?.Q),1.J'. L................~ .........Race...............,~!:t.~.t..f:'.

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.................

Casket ..............................................................~ (Style) (No.) Outside Case or Vault................................................. . Embalming Body .................................... ................... . · ........ · .. 1 Professional Service ................................................... .

:::::::::::1~:i~ o~r~s::~.::::::::::::::::::::::::::::::::::::::: :::: :::::::::::::: ::::::

Date of Birth. .....N.Q .y..elUh"r....J.Q.......J9.59.......... .. Age...........................................................?.h2.ldF..i?.. . (Year s) (Months) (Days)

Shirt, Collar, Tie ...................................... .................. .. Shoes $....... _............. Hose $...................... .................... Underclothes ............................................ ................... . Door Spray .................................................................. .. Gloves $.................... Chairs $.................... .............. ...... Flowers $..................Palms $.................................... .. Cremation ....................................................._......... ..... . Newspaper Notices .................................................... .. Telephone and Telegraph ....... _............................. ...... Ambulance ................................................................... . Funeral Coach ............................................ ... _.............. . Passenger Cars ................................................._.......... . Pall Bearers' Service..........................................._...... . Transferring Body.................................... ................... . Opening of Grave.......................................................... Cemetery Charges .................................... ................... . Lot .............................................................. ................... . Misc. Transportation .................................................... Shipping Charges .................................... .............. ...... Clergyman ..................................................... ............ .. Singers $................ Organist $................. . Cash Advanced .......................................... .................. ..

How Long Resident in Community.............................................. _............:..: ......... __..____ .................... __ .. _...... __ .... __ .... .

Single........................Married........................ Widowed....................... Divorced...................... Child .....ch11d ....... Husband, Wife or Child of................................Haz.el.. D.rx............................................................................... Address ............._........_.. ____.. _...._.. _.._.............•.........o!...~!.1:!t.~~.§., M.*'~ s.~y!'.~ ..........................................

.....

..

Closest Relative......._........... __................................................:.. __.Address ...... ____.............................. _....................... .

Father's Name............._._.... _.............................. :: ........... :_._: ....Birthplace... _........................................................ . Mother's Maiden Name.. _____ .........................................................Birthplace.~.:. .................. _.................................... . Cause of Death............._................................................................ContiibutOry..~ ...................................................... . Date of Death...........No.v..Elmher.....ll.,.....195.9...........:.. .Hour...................ll...l'... • ............................... Place of Death...... hQme....................................~·. :.:.:~~~ ..........·... .How Long III ? ..................................................... Physici.n ...........Dr.•.... E •....E.....

c.Dan.lf:.l.................... Address ... .Q.a.§.§.YJ.1)..~.•.....Ml .1Hl.9..\.!.r.: t

Occupation of Deceased. ............................................ _................ Social Security No .............................................. Nanle of Employer........................................... _............................................................................................................ Address ..................................................................... _.......................................................................................................

Charge to.......... Ml'.•....& .. .Mr..g.•....W1.1.s.on .. D.r.r.............Address ..........J .enkina •....M1 a.s.our1 .. Order Given By..............................................................................Address................. _............................................. ..

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P.... .

Date of Funeral.....De.Q.Il.mb_e.+:'.....L .....19.5.9......................Time...................? .. M -'... ................................ Place of Funeral Serviee....:........ _.................. _........... _.. _................................ ;..:.................................................... _. Clergyman........ R~¥.•....Lo=...:s:all-l.e¥..........:.............. Call for? ................................................................ 1" 1 ......... ,. _. .11 Address..........._.............. &-8.8.11.1 IIe •.... _"-'-a.sO'll.r.

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C.

Remains to be shipped-see reverse for details.

\

Lot No ............................................. Section No ........ :...... ~ ........................ \ Ramarks ....................... _,;-'....p.Jn~........~."'.:!:1I:

... p.:I:1:l.~J.t.............. ... ......... ............................p.J!lt....Cl.F.~.l?.~... JD.~.~.:r.J.'?.:r.......:...........I., .......................................~.~.~::".y~9.:;J.-... .9.§:.§.~~.t.....g.!?.l............. _.........!

==:=

Total Amount. ................................. I- - -1

~

Interment at................._.....O.ak ...~e ....c.8m.e.t.ery............\

FORM 1523 " SUPERIOR FUNERAl. SUPPl.Y CORP .. Cl.EVELAND , OHIO.

==::=:::\ ::::::::::::::::::::::.::::::::::::::::::::::::::::::::::::::::::: Information Given To: Relatives o Musicians

o o

Lodges Pall Bearers

o o

Death Certificate Payment Arrang'ed

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Attended To:

o o

o o

Clergyman Singers

Permit Bill Rendered

Insurance......................................................................................... .