122 Date.... NQ.Y..erob.e.r.:...}.•.
_.12.9.0
.
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF Yearly No.... _.. _.._..122... _...... _...
No........ _.._.._.. _.._ _ _
Cask.t ............................................................ (No.)
N ame. ...... _.......................... Y..~lm.~...!?~.g/?.~....K..~J~x....................................................Sex............re..lll1l:~.e.
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Address................................. _...Eo.rm.a...Q1.ty ..... .QI(!,iWg.!!!~.................................................................:..... County...........KaY................_.. _... Township......._.. _..................................... Phone No ........................................... .. Where Born............._...__... _..._...._................_.........._.. J ;dlB..§9_\!,;rJ,........Race... Wh.;h1;..~........................... ..
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Date of Birth. ........WgUs..t..2.1.~
.....l9..Ql.................Age.....................5.9........................................................ (Years)
(Months)
(Days)
How Long Resident in Community...... __ ........J}.._¥-..e.:?vr.S ...__ .......... _....................... _............... ___ ............. _......__ .. . Singl............ _..........Jllarriedl!laI'.r.1£l.d . Widowed....................... Divorced...................... Child........................... . Husband, Wil. or Child oL ..................... Ear.l...K.e.lly..................................................................................... Address ......................._.. _...._........ _...... _........P..o.nc.a....Q.1.t.y....... Qk,AiWg.!!!il................................................. Closest Relativ.....Mr..s...... B.A....T......MilJ..ik1n.............Address ............HQ~.!?y2g, ... ,1'.!'i.~§\.~......... Father's Name......:r.ohn.. Black............................... _.. _....lIirtllplace.............................................................. Mother's Maid.n N ame.......
F.19..r.~ ..........................................Birthplace..:...........................................................
Cause of D.ath....ACl.ut.e. ...Q.Qr.O.na.r.Y.....Tb.;rQm.R.Q.J?~oiltributory ........................................................ .. Date of Death ......... NQ.y.e.mb.er. ...}.. ....19..6.Q...................Hour........................................................................ Place of Death ............................................................................... .How Long Ill? .................................................... . Physician...........................___.....__ ..................... __ .. __.......................... Address. __ .__ ..............._.... ___ .. ______ ............................ . Occupation of Deceased. .............................................................. Social Security No ...... __ .... _..................... _..._...... . Name of Employer........................._.......... __ ..... _.............................................................. __ .... ____ .................. _................. Address ..................................... __ ........................._.... _..................................................................................................... .. Charge to................................. _................................................. __ ._Address ............................................. _.................... Order Given By......................................................................... _...Address ................._.............................................. . Date of FuneraL .......N.O.1T.e.mb.e.r.....6......1.9.6.Q................Time .....................
? .J'....M....................................
Professional Service ................................ H~ Dre.sseI: .............................................. Suit 0 1' Dress ... ............................................. 1.............. 1.... . Shirt, Collar, 'ri.e........................................................ 1.... . Shoes $...................... Hose ~ ........................ I............. Underclothes Door Spray .................................................... 1 ............ . •....·.. ·.... 1Gloves $.................... Chairs ~.................... 1.............. Flowers $..................Palms Cremation ..................................................... 1........ ..... . Newspap er Notices ................................... 1............. . .. ........... 1 Telephone and T"lelrraph .........................I........... .. Ambulance ............. 1 Funeral U c'ac.n..................................... ........... I............. .. ........... .1 Passenger <.;3'"s ........................................... I...... .. ........... 1 Pall Bearers' Serviice· .... · .... · .... ·.... ··........... .. ........ · .. 1 Transferring Be'dy ......... ··.......................... --I-.............. I...... .. ........... , Opening of lirav'e........................................ I.............. I...... .... · ....·.. 1Cemetery Charges·· .. ··· .. ·············· .. ·····.. ·· .. I·.. ·.... · ....·I ..·· .. .. . ........ 1 Lot .............................................................. 1............ + ... .. .. ........... , Misc. Transportation ..............................__ I............ 1 ...... Shipping Charges .................................... 1...... . ........1-..... Clergyman ................................................1.............+ .... Singers $................Organist $...... ,,_. _....... 1............ .. 1 . . . . . . . . . . . . . . 11 . . . .
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Plac. of Funeral S.rvic........ G.u.-l¥4l.v..Ls_..Ch-'lP-e.l
.........................:............................................................. Clergyman..............Re.1T...... Gha.s.~ ...1[anZ.amj.1;.............Call !Ol' "I. ........................................ ........ :........ . 111e Mi ssouri
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Remains to be shipped-see reverse for details.
Interment at. ..................... ~.~S~!lUI~l... ~J~a~..:..L~....~e~~~.k"' hCJ ....................................: Lot No ................. __ .......................... Section No ............ _............................... Grave No ............................................. .. Ramarks. __ ...................._................................... __ ......................................................................... __ .. __ ................ __ ............. .
~ -~ ~~dges ~tr'Pall Bearers
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o FORM 6 235 SUPERIOR FUNERAL SUPPLY CORP .. CLEVELAND, OHIO.
Information Given To; Relatives Musicians
Death Certificate Payment Arranged
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Attended To:
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Clergyman Singers
Permit Bill Rendered
123 Date. ....N.QY..e.mP..~.:r....1.~.....
:),.2.2.0
No......................_
,
FUNERAL
.
.!..,].............
_ __
Name.......................... M.~~Y.:
CHECK EACH ITEM AS COMPLETED
RECORD '01" . Yearly No...................
Casket ..
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Address .......................... Ea.l!,:l
e....RQ.I<~J.....M.t§.flg.!!:r.J......................................................................:............. '.
Outside Case or Vault............................ .. Embalming Body ................................... . Professional Service .............................. ..
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COunty.BarTY-...........................Township.................................................. Phone No............................................ . Where Born........ T.eJlIl~..Il.!?~..~ ................................ _.._ .................................R.ce....................... I'!J::l.~.~.~
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.........
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.6.9..........Age...............(Years) 9..9.....................J,.~ ....................~!±...... (Months) (Days)
Dat. of Birth........ N.Q.y.em.b.e.r.....?...3.......l.!:l.
How Long Resident in Community........................................................ _......................................... _......................... Single....................... .Married ........................ WidowedNJ.Q.Q.lY..~ .d.. Divorced...................... Child ............................ Husband, Wile or Child of.............•............•...•...J.Q.s.e.l1h....T. ...... l'x1.e.:r....(g..~.9..~gJ?~g.J .................... . Address ............................................................................................................................................................................. . Closest Relative.......J.ohn.. P..r.l.e.:r......................................Address ............ ~.\,t~9:Y..I.....M .*-S..~9..t1.~~ ..... Father's Name..J".Q.1:tn....stLu11.................................. _.._....Jlirthplace.............................................................. Mother's Maiden Name..._..Ma.ry ...Ja..!Ht ...B.:r.9..I?1>.!? ......Birthplace............. ·····························l ·····::t:······ Cause of Death.. ..l~(..~ Contributory.(,!..e..~.~g.".l!.v..~ .J.~(.L ..
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t" H 't 1 n.J..C...• Q.•~;p......."L..............How
Long Ill? ................................................... ..
Physician..........Dr .......G._....H. .....J.Qhns.Q.n .......:................. Address ......... Q.i3,.El.fl.yJ1..;J,.~ .,.....M.1..~.El.Cl.\;:r.l Occupation of Deceased.. __ ..... hG~~. g.€-l;,l.i.:t'. €- ......................... Social Security No .............................................. Name of Employer ........................................... _... _...................................................................................................... . Address ............................................................................................................................................................................ .. Charg. to..... J;h.1.1d.:r..e.IL ..................................................... _.Address ................................................................... Order Given By.....................Qh.t11.r...:lL.............................Address ..................................................................
Date of Funeral... ...... .N.Q.y..e.m'Qf:.;r.....;U~.... J.9..Q.Q............Time ............? ...f
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Plnce of F uneral Service..............Ro.ar..1ng...E.1.v.~.:r.....B..p.J2.1;.;l,.§.1;....~.b-.1.,lT.Cl.l1.:::.~.?$1..~....F.t9.c::..~... Clergyman........Ed..i.fj._E.'"~lelf..~..Be=e.t .t...................C~1l for? .............................. :.............................. _
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Shoes $......................Hos. $...................... . Underclothes ........................................... . Door Spray .............................................. .. Gloves $.................... Ch.irs $1t.~ 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 ......................................... .
I ............
L..h?e,Y.I.C).\.. ..E,a. ............. . EIf, "D.te of Death... N9.y..~m1?~.r..... :z~. ...:L.2.§9........................ .Hour .....................} ... A •....M.............................. PI.ce of De.th .. D.S....e.O.pa
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Remains to be shipped-see reverse for details.
Inoormentat.......Jll~nQs)y. __ ~.~J.P.~~£~;r.;Y..........................~
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Bearers
Lot No ............................................. Section No ............................................ Grave Ramarks ...............R.:r.9A.19,....(lh.a.1.e.g, ....§JJ:v.?.r..... P.~.J:'.f..~g.!:..~.().I?: ..................................................... .
.................................lIlh.l.t.~....Q.r.~p..~.....1."'J..t\?r..±Q.r..... .Y!.:1:.~J:l.... c.>.r..()J:l.:i.
Information Given To: Relatives 0 Musicians
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Death Certificate Payment Arranged
Attended To:
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Clergyman Singers
Permit Bill Rendered
Insurance ......................................................................................... .
124-
Ii......126 0
Date. ...•N.Q.l[~.m);'-~.I:....;t...
.. . . .
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF 1 24Yearly No........................................ .
No........................_ . _ _
Name. ................................11l0r.thY.....;;J.arnJ.l.e.l...E.l.Q.l:1aJ?.Q.s.Qn ..............................Sex. .... m.~;t..!'L .......... Address......................................J .2LLlL .....~5.1;h ...r..~Y..;:'.g,Q..~ .,.....K@.§.?:.~...
.9..tt.y...JilQ..,...................
COunty....J..a..c.1H).QJL..............Township ..................................................Phone No ............................................ .
Wh.re Born. .................Ga.s.S.:::C.Q.UIltY..•.... Ml .5..i;l.Q.U.J?j,..............:.........Race..............wh..+.t.§...................
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Date of Birth. ....r.anu~....12~8.9.6....................... Age...................9..~ (Years)
.........................................................
)
(Months)
(Days)
How Long Resident in Community.......................................... __........................................ __.. __. __ .... ___ ........................ . Singl• ........................Married. ..))lg,:r..;:'.".§.~idowed.......................Divor ced.......................Child........................... . Husband, Wit. or Child of........................... Ruby.... Ri~har.Q.s.Q.n. ...............................................................
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Address .............................3..?~....YL,.!±.5..~....T~E.!.:?,~.~ .I.....~i3:.n.:~:':.s.... g.~~.1.!..... ~.~.s.
Closest Relative....Rll.by... R1.cha.J?Q.S..QXL .......................Address ......~@.§.!l,~....QJ:t.y..•....MJ.~.§.!? !,lrl Father's Name.........E.t:g.pJi...Rl9.h.g.!:g.§.9IL.................Birthplace.............................................................. Mother's Maiden Nam•.......Ra.s.e....D.emO.r..e.tt................Birthplace............................................................. . Cause of Death.... ___.................................................................... _...ContriDutor'y.~::·~............:.. -"...................................., Date of Death ...... J\!oY.. emh.e.r
... l .6.•.....l9.6..Q...................Hour ........... 9..;..it.5..Ji'..,.M.,.................................
Placo of Death.. .6.:t..•... J.9.hn.!..:;c... .6);lT.1ng fJ.§J90 .....lIow Long Ill? ..................................................... Physician ...... D.r..•...J .ame.B. ...Br.O.w.U................................... Address ...... !?ll.:r.J.l:lg;!'J~.JA> .. ..!V!J. I?f?g..i,lr 1 Occupation of Deceased.. :r..e.al ....~.!?:t;.g.1;.~....p..rg.k~.;:'... Social Securit y No ..........
5.:L..Cl....?.c:>...!±1i:.Q()
Name oi Employer........................................... _..._...................................................................................................... .
Address ............................................................................................................................................................................. . Charge to ......w:ido.\Y.....................................................................Address ................................................................... Order Given By.......... -S-O-f.l..................................................... _•. .Address ................. _............................................. .. DareofFuller.,L ........_...NQy.elllhElr..... ~;).~ .... 1~1Q:Q ........:rirn.e .....................~; ...li'.,]V!., .................................: Place of Funeral Selcvi('e.............. .NJ~Y!.C.Clme.r!.8••. J.j.h!.p . ej......................................................................... : Clergyman ........................._.............................................................Call 1 01" ...................... ...... ........ ....•.... ..
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............ /Casket ....................................................... . (Style) (No.) Outside Case or Vault.............................. Embalming Body ................................... . ............! Professional Service ............................... .
.. ......./::i~ o~r;~ees:·:::::R9:i?~::::::::::::::::::::::::::
I
.··· ...····.1 Shirt, Collar, Tie......................................
........... i Shoes $...................... Hose
$..................... .
••••••...... 1 Underclothes
........................................... . Door Spray .............................................. .. ............ / Gloves $.................... Chairs $................... . ............ / Flowers $.................. Palms $................. . ···.···· .. .. 1 Cremation ................................... - ........... .. ............ / Newsp&per Notices ............................. _.. . ············1 Tel.phone and Telegraph........................ •••••......•. 1 Ambulance ................................................ ............ / Funeral coach ............................................ 1 ...·········1 Passenger Cars ......................................... . Pall Bearers' Service ............................... . ············1 Transf erring Body.................................. .. Opening of Grave..................................... . .··.········1 Cemetery Charges ................................... . •••••••••• •• 1 Lot ............................................................ . ·.· ... ··.... 1 Misc. Transpor tation .............................. . Shipping Charges .................................. . Clergyman ...................... ,........................ . Singers $................ Ol'ganist ; ................. . Cash Advanccd ...~.~.?-.:t;.l1. ....CJ.~.r.t;....... .J?a .l.e.
Total Amount. ................................. , Remains to be shipped-see reverse for details.
Inrermentat .......~!."
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Lot N o............................................. Section No ............... _............................Grave No .............................................. . Ramarks ........................g;t;>.a,y....1S...g6l-•....per.f.ec.t .ion ....shr..ine....sealer................................
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Information Given To: 0 Relatives 0 Musicians
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Lodges P all Bearers
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Deat h Certificate Payment An-anged
Attended To:
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Clergyman Singers
Permit Bill Rendered
Insurance ........................................................................................._
Date. ...........NQ.y.amb.Sl.:r...
_U....... 19 60
... . FUNERAL RECORD OF
CHECK EACH ITEM AS COMPLETED Yearly No.................~?5.
No..........................._ _
...............
Name................................................. Mr..s.•...BQ~e..s........................................................... S6L ..r..~.lI!§,.~.~ ........ Address........................................................p..Q~!.~.i.:)!;.I...)!!i.'?.El.C!.~:r:.1....................................................................
COunty....................____ .. _...... _.. _...Township ......._.. _.... _... _______ ... _______... ____... Phone No...................................... __ .... . ,W here Born. ............ _........_........ _.................................. _.._ ...._............... __. ______ ... Race_ ................................. ___ ..... __ ... .
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Date of Birth.........................................................................Age................................................................................. . (Years) (Months) (Days)
How Long Resident in Community........................................................ _............... ___...........__ ... _......... _...... __ .___.___ .__ .. . Single........................Married........................ Widowed ....................... Divorced...................... Child .......................... .. Husb.nd, Wife or Child of...........................................................,............................................................................... . Address ............. _.............................................................................. ::............................................................................. .. Closest R.lativ•. _.... _.....................................................................Address............................................................... ..
Father's Name....... _.......__.._..._......................................... _.. _....~irthpla~e... _.........................
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Mother's Maiden Name............................................................... ...Birthplaee... _.... ____ ................................................ . Cause of Death...............................................................................Contributory.. ___ ..... __ ...... _........... _................. _......... Date of Death....... NQl1.e.mb.er....l.7. .....19.6Q..................Hour ......" ................................................................ Place of Death ............ __ .......................... ____................................. ___ .How Long Ill? ..................................................... Physician .......................................................................................... Address .................................................................. Occupation of Deceased. .............................................................. Social Security No ............................................. . Name of Employer ........................................... _............................................................................................................ Addreos ........................................... _................................................................................................................................ . Charge to................................. _.................................................... _Address ................................................................... Order Given By__ ........................................................................... .Address ................................................................ .. Date of F uneral.. .........1l!.Q.1Lemb.e.r...l
9...... ~9.6.Q............Time ........................................................................
Place of Funeral Service... _........ _.................._... _...... _.. _...................................................................................... ___. Clergynlan ......... _..............__ ................ _......................................... Call for ?.............................................................._ Address........... _...................................................._ .............................~_........_.... __....__................................. __ ............_.. __
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125
(B oone )
Casket ........................................................ $..................
Ca~~~:ef
(.~~:)
Outside ault ........ ............................ .. Embalming Body .................................... ..........__.. ..... . ............ 1 Professional Service .................................................. .. . .... · ..... . 1 Hair Dresser ................................................................ .. ............ 1 Suit or Dress ............................................................... . Shirt, Collar, Tie ......................................................... . Shoes $ ...................... Hose $.................................... ..... . Underclothes .............................................................. .. Door Spray .............................................................. .... .. Gloves $.................... Ch.irs $.................... .................. .. Flowers $.................. P.lms $................................ .... .. Cremation ...................................................................... Ne"\\'spapcr Notices ................................................... _. ..· ...... · .. 1 Telephone and Telegraph ............................................ Ambulance ................................................ .................... Funeral Coach .............................................................. .. Passenger Cars ............................................................ .. Pall Bearers' Service .................................................. .. Transferring Body.................................... .............. .... .. Opening of Gl·ave..............................._........................ . Cemetery Charges ........................................................ Lot ................................................................................. . Misc. Transportation.................................................. .. Shipping Charges .................................... ................... . Clergyman .............................................................. ...... Singers $................ Organist $................. .............. ...... Cash Advanced ......................................... ....................
I: : : : : : : : : : : ::::: : : : : : : : : : : : : : :: : : :
:::=::::::: I::::::::::::: ::::= - ......·I ..·..··· ..·..............··· ................................·...... ···-,~. Total Amount. ................................. - --
_
Remains to be shipped-see reverse for details.
Interment at..............F.QJ:\...Q.~.m?.!;.~.r.Y. ................................................................................................................
Lot No ............................................. Section No............................................ Grave No ............................................. .. Ramar ks ............................................................................................................................................................................ .
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Lodges Pall Bearers
Information Given To: Relatives Musicians
'0 Death Certificat.e Payment Arranged
o
o o
Attended To:
o o o o
Clergym.n Singers
Permit Bill Rendered
Insurance...............................................................................__........ . FORM !las !I SUPERIOR FUNERAL SUPPLY CORP ..
CLBYE~ND,
OHIO .
126 Date. .... NQX.eIDhl;lT..
_J.L.._.12 60
. .. .•. .... . FUNERAL RECORD OF
CHECK EACH ITEM AS COMPLETED
Yearl~ No.... _.. _.._l2.6 ..... _......_...
No........_.. _......_.._.___
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(No.)
Name. ......_........_............ _..........Iufa.nt....gl:r..1....Il:Q.Q.sln.lgh.t.............................. Sex. ........f..~.~.+...~..
outside Case or
Addrees ....................... _........ _........_.._.... _J..~.Il.e .... _M.t§.§g.h\r.J...........................................................................
E mbalming Body
County..MuD.Qna~d. ......_.. _...Township......._............_........................... Phone No ............................_.............. .
Professional Service air Suit or Dress Shirt, Collar, 'T'iJ S hoes $......._.............Hose ~ . U nderclothes D oor Spray . Gloves , .................... Chairs Sl F lowers $.................. Palms s. Crematiol1 N ewspaper Notiees .. T elephone and A mbulance Funcral r.{ PH P assenger Cars. Pall Bearers' .. Transferring Bodv.. Opening of G, ~V< .. Cemetery Lot Misc. Shipping Charges .. Clergyman Singers $................Organist S. Cash A
Where Born............. _...lil.e.ll:tOnv.ille.,._.Arkan.saS........................ Race..............W.!'.! At!'L ................
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Casket
Dat. of Birth........NQ.y..e.illQ.e.r....
(Months)
(Days)
How Long Resident in Community........................................................-:-:................................................................. . Singl .........................Married. ....................... Widowed ....................... Divorced ...................... Child............................ Husband, Wife or Child of...............................D.ema....G.O.Q.dn1gb.t........................... _................................... Address ....... _.... _............ _.... _................ _............................ J.an...e......MJ.§.§9..~.rJ ............................................... Closest Relativ•. _.... _..~ma....Go.o.~t ................... _.Address ......... J.an...e......M.;l..§..§9.1J.r.;!, ......... .. Father's Name...Cb..ar.le.S...G.Q.o.dn.1gh:t............ _.. _.....Birthplace............................................................ .. Mother's Maiden Name.......12e.ma....MQr.g~J!.....................Birthphice............................................................. . Cause of Death __ ..______... ___.__ ....................................................... ___.Contributory............__ ............................................ Dat. of Death... _......NmI.embe.r. ... l.i'.•....19.6.Q...............Hour.................. $..;)·.9. ..
J)..,.!~..,.........................
Place of Death ...... B.at.e.s....MeillO.r..taJ. ... HQ.!?.P..,......... .How Long Ill? .................................................... . Physician .......Dr ...... N.e.il....C.O.mp . t.9.U............................... Address ... ~.~.!!.:t.c:>n.v.:.1 J,.~.~.l ....
..
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Occupation of Deceased........__ ..................................................... Social Security No. __ .......................................... . Name of Employer: ... __ ..__....... __ ........................................................................ __.......... _____ ............................................ . Address .................................................... __ ................................................................................. __ .................................... . Charge to.............Dema ... G.o.O.drl.i.gh.t ............................. _Address ................................................................. . Order Given By........Mr........&... Mr..l3..,.....Y.:~9.J.§ ...M!?.r.g OOdress ................................................................. . Date of Funeral.. ..... ,NO.1f.ember. ... l .9......19.6.Q...............Time ............ :.........~... J) ..,.1.I.,................................ Place of Funeral Service............._Dent....!leme:t.er.y....................................................................................... Clergyman...........l?.auJ._.E@z:lbes.t......................................Call for ? .............................................................Address...........................c.a.s.8.1l.ille.•.....li1.S.,SQ.\l.r.i....._.._.............................. _............................ _.............
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.. T otal A
..
Remains to be shipped-see reverse for details.
Interment at................._..Dent....Gemet.e.ry .............................. ., ......................................................................
Lot No .......................... _................. Section No ...............•...... __ ... _______ .... _____ .Grave No .............................................. . Ramarks ....................... -2.L..1ciJ.i.t.e... do.e............................................................................................................ .
............................................;mi.t .e. ...S.tain....t~I.J.)..J. ... 1.n.~.s:.~,:i,(). J:'........................ .............................. ................................................B.en:::.\y.aJ ... .(l.!it§.~!?:L.9.g....._................................................................................ F ORM 152.35 SUPERIOR FUNERAL S UPPLY CORP •• CLEVELAN D, OHIO .
.... _--- ...... ...... ........__ •... ......
·..··..·· IH
Jl........J9..9.Q.........Ag.......... _........... §.:t..i..~.:I:~.i.E.~l1:..................._....... (Years)
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D Lodges o Pall Bearers
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Information Given To: D Relatives 0 Musicians
Death Certificate Payment Arranged
.............. ...... ------_ ....... ......
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FUNERAL RECORD OF ' No•......._.. _......_.._._.__
Yearly No•..._.. _.. _.t.,?l...._......_...
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Name...._._......................RlJ.p.y_..,r..lJ.§J.'!.~.j;.~...R~.g.fb..g.L!·......._.....................................Sex. ..J.~.i!!gJ~........
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Addrees................................. _..p..1e.r.C.e....C..1.ty • ....MiS.i>.,,1l..r.1 .....................................................................
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County......... Layn:.e.U9_{l_.. _...Township ....... _........•... _...........................Phone No............................_............... Where Born. ............_.. __.El...RenQ.~....O.klahQma ... _........ _................,Race ............wh.1.t.a ................... .
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······ IProf essional Service H air Dresser. ············I Suit or Dress ............
Date of Birth. ........ E ebr.uarY-....1J~....19.11......... Age.................4-.). .................................................._....... . (Years) (Months) (Days) How Long Resident in COmmunity........................................ ____................................................................................ .
Single....................... .Married. .......................Widowed.:..W.,i,g9.l'!.~.j}ivorced...................... Child............................ Husband, Wife or Child oL ......................H....v .schOl.l ...Mcl'.ha.:i..l ........................._................................... Address ....................... _.._..._ .. _...._............ _...........................Dec.ease.d..............:: .............................................. ............ Closest Relative.....J..ac.k.1.e....L.•....MQ.P.h.a.~J..................Address.......... MQ.!1~.j;.j;.•....MJ,.\Hl.Q.lJ.r..t ... ............ Father's Name....l'ii l liam...G.•... Rar.t.on ........__.. _.....Birthplace... _............................_.................._...... . Mother's Maiden Name... _lg~...J-!g.~....B!??!.!L...................BirthpIace........ . ............ _..................................... , ............ "lY\· ' · .. 1 ~ ~.< CI..&.~ r ... C · ·b · A" ,',~ ''''J J. t.Ll. ············ Cause 0 f Death ..I ..\ .l~.#D..... ___ ........ __ ._ .. __ ... _..... _..... __ ... _.... antrl utory....__ ...................................................J..i
Shirt, Collnr, Til Shoes $......................Hose $. U ndcrclothes D oor Spray Gloves $.................... Ch.irs $. lowers $.................. Palms iI: Cremation N ewspaper Notices .telephone and Ambulance F p unel'al Coach assenger r.l P all Bearers' T ransfclTing Bild, Opening of r,.~ Cemete:ry L ot Misc. Shipping Charges Clergyman Singers $................Organist S. Cash A
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Date of Death ... _...NQ.lw .mb.ex ...2.1•.....l.9.6..Q..................Hour............. S .. .'ltL.........................:........... Place of Death.S.un.s.e.:t....1fall.ey....B.e..il.t .. J:!.Q.!!U;L ....How Long III ?.................................................... . Physici.n .......... llr.•... Mary ... N.e.w .man .............................. Address.,........... Qa.s.i>:v.1.1.1e.•....MQ .•........ Occupation of Deceased. ..... ~ab.QJ.:e.~...J.n........................ Social Security No ...!J:S.5.~.1.6::':.3.25.6........ Name of Employer...................Garme.n .t .. _f.a.C.t .O.r.:v........................:..::...... '...................................................
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Charge to .......... Insuarnc.e ........:.:..................................... _Address................................................................... Order Given By........ i.arnl1:v................................................... .Address.·................................................................. Date of FuneraL. ........N.o.v.em.b.e.r. ...2.6, .....196'O'...........Time ..........L ......2 ...P. .• l ..................................... Place of Funeral Service............Q)JJy..:? r..~_§._.9.J:l_§.p..gJ................................................................................... Clergyman ....... .R~.Y: ..-.....QlL"..§ .., ....ya!!:~.g.P..9J!.................:Call for? .............................................................._ C a _s ............ s ville Mis_sou ri 'v .. .. Address........................... _.... _. 7.............. .. ............ ......•..... _ .. _ •.......................•..... _ .......... .......... .. ...... _ ...•.. _ •. _ .
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Remains to be shipped-see reverse for details.
Interment at.......Ar.nhart ... .G.eme.t.er.y.. ........................................................................................................ . Lot No ............................................. Section No ................ ............................Grave' ,
Ramarks ...............29.5....Qr.chl.d . ... shadad. ... s.1J:v..e.l:'... J?.t .{l.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
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Paym ent Arranged
0 Clergyman 0 Singers
Attended To: 0 Permit Bill Rendered
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128
12.9 0
Date. .. N.Q.1l.e.mb.e.r._.2.Z......
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CHECK EACH ITEM AS COMPLETED
FUNERAL ,RECORD OF
No•....... _...•......_.._.._.._ _
Yearly No •... _...•.. _...
J.?!L ...... _...
COunty... _......................_......_..__.Township ......._.._........ _...........................Phone No ............................ _...............
(Style) (No.) Outside Case or Vault. __ .__...................... __ . Embalming Body .................................... . ._____ ...... ] Pr~fe s sional Service _...................... ___ .... __ H D
Where Born._.........
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Name. ......_........_............ _.................E.e.r.t.....S.li.:t..tJ&!L.........._.....................................Sex..........!!\~J.(l........
Address ......._......................._........ _.B.g.l!,.'!!.~....#..;J,._.......!? @.~.£Y..1T.~.:J,.J,.tl.l .... ~t.\C.1l..r.t.s. ~.s.
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Date of Birth..J ..,m.li.aJ:y....J,gL.....l$..25...................Age ..........•.. _... ..9.5.......................................................... How Long Resident in COmmunity..........................................._...........
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Cause of Death.~.~~..Contributory.......................................................... Date of Death ... _...No.v.amb.e.r. .. .22.•.....l9.6D............ :.....Hour........................................................................ .. ...
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Name of Employer........................................... _.......................................................................................................... .. Address ............................................................................................................................................................................ ..
Charge to............. WJ .Q,gYL._ .................................................... _.Address .................................................................. . Order Given By..................wido.?J............................................Address ................._.................. _.... _.................... .
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P II B ' .. .... ................._... . •........... a earers 'Servlce ......••.... Transferring Body.................................... I ............ Opening of Grave............................... _..... ,
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Place of Funer.1 Service ......... _.._McGu.i.l!a _.Ce.mate.r.y.......................................................................... -. Clergyman ......................... ___................_............................... :......... Ca11 for? ....: ...........................................................
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~~::esS~".:~.:::::::.::::.~~;;;~.. F l owers "'. ...........____.__ P a Ims $.........______ .__ . Cremation .................................................. J Newspaper Notices .................................. Teiephono and Telegraph ........................ Ambulance ................................................ .I •
Address ....._......_...._._ .._..._ .. _.... _.. _.._................ l3.e-r.r.)f-... J!.ille,.... J\.r.kanac..s..................................... C10seet R.lative ....... .J)!r.S._....~e.s.s.ie ... .s.u.t .t.le.s .... .Address .......... E.e.r.;r.y.y...iJ,.le.•.... A~l\;an.aas Father's Name.......Jol:u:l ....8.uttle.S......................._.._.....Birthpl.ce... _......................................................... J\ ,., n Hi 1 ton Mother 's Ma,'den Name·····:··... ,········7r:;;;···::F.. ·;;-·:···········;i ·.B,·rthplace'... _.........................................................
Date of F uneral. .......N!:l.Y.e.mb.e.r.... 2.6.•....J.9.6.Q...............Time ..........? .)'..,.M .'-........._.................................
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Place of Deathh .O.m.e....o.f. ... A •....B..,.... ~lagQJ},<;lI'............How Long Ill? ..............................................._.... Physici.n ...........Dr.._....G._.....~.•....P.Ur.1r.e.a........................... Address .............Q.aJ?.eY.J. :J,J,.~.•....MJ.§.f,lg.l.l. r Occupation of Deceased. ...f-a-pme.p ......................_................ Soci.1 Security No ........ 0.
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Shirt, Collar, Tie ......................................
Single........................Married. .. .mar..r .d,§?Widowed....................... Divorced..................... Child. . ......... .... Husband, Wife or Child oL ..........................'I'.r.e.s.s.ie.... Su.t .t.las.........................._...................................
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Cemetery Charges ................................... . Lot .............................................................. Misc. Transpol'tation ................................ I Shipping Charges .................................. .. Clergyman ............................................... . Singers $................ Organist $..................
==::::::: ~~~:::::::::::::::::::::::::::::: I =:=::=::: \ :::.:::::::::::::::::::::::::::::::::::::::::::::::: :::: ::::: •• ::.
Remains to be shipped-see reverse for details.
Interment at......._M9.~ ..l-!.tEtl.... Q.@.~~.~ .E).£y. ..................................................................................................... Lot No ............................................. Section No...........................................:Gr ave No .............................................. .
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Date....~.o.'!l.emh.er....2.6.,...
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FUNERAL RECORD OF Yearly No ............ _.....;t,i;5L.. .........
Casket El,Il.r..Y.J Q.Il.,$. ................................ (Style) (No.) I Name. .............................._......aa.d.1.e....C.. ,
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Interment at.. ...........'Has.hbJ.l:r.n..... ~11,$.-'!.Q"'.r.;l, ............................ Lot No ............................................. Section No ...........................................)
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CIlECK EACII ITEM AS COMPLETED
OF .
N 0 ••.•••.•_ ••.••••••• _ •• ___•• _ _
Yearly N 0 .... _ ...... _ ..
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Where Born. ............_Barry..._C.Qunty..,._JIU:6.flQ.v..r.J. .... _.................Race .............. )~h.;b~.\L. ...............
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Date of Birtb........._....... J.~!}~g,r.y... 3.},~.....J.:~§.:t. Age.............. (Years)
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How Long Resident in Community.......;!..Q... Y..~§'.r..s.
J2........................................................... . (Months) (Days)
.............................................................................................
Single..........._.......... .Married.... mar.r..1.e.Widowed....................... Divorced...................... Child........................... . Husband, Wife or Child of........................... ,Ha.:t.:t.1.e....!:!lJ.ill..Q.)1 .. J.QI'.Q,§,!} .......... _................................... Address ..... __.... _........ _.._........_ ................................Q?:_i:1&Y.J.n!eL ...~~.~:9..El.o..~r..~........................... ..... Closest Relative .......Hat.tie...J.Q.:r.Q..an............................Address ............':::?:.§.!?'y'.P:;J,.~.,.....IVl:1..S..§g.1J. r i Father's Name..........I9.!2n_.;r..~.!.:9:§'.JOl
..........::..:............._.....Birthplace............:.................................................
Mother's Maiden Name..._......M?:.~Y.. ....:[,..g.!'!:g.........................Birthplace... _........................................................ . Cause of Death .. Q.Q.;r.Q.D.a.;r.y.....tht.9..I.!\1?9.. ~J.~................Contributory... :....M::t\l.~:.+..?g.;!,!?t..C?~.:1..?. ..
Date of Death... .N.Q.Y.eIUQeX:....29.~....J9..g.Q.....................Hour............ l?.;.}Q...A.,....M..,...:..................... Place of Death .........hQIUe....... _........................:........................How Long
Ill? .....................................................
Physician ....... Dr....... G......,H......,J.QDnJ?.9.)1 ...........................Address..........g.~.S..S..1T..1..:t..:l:~ L ..~.~~.B.9..\lT i
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Occupation of Deceased... f.e..:r.!!l~..f........................ _................ Social Security No ........... 5t:J<:l:::g.~:::§.g!:l-.?
Name of Employer....... ______ . ____ ......................... _..........._....................................................... _... ___ ................................ . Address __ ................................................................... _............................. __ ........ ____ .................................... __ ......................
r..s.......Hp.. t.tl.e... J.Q.:r.Q.iW................... _Address ....:..Q.§l.El.ElY..,i..1.J.i3.L ..1I1:i..§..B.c:l.lJ!'.:i. Order Giv.n By........ cr..S.. ,....H.~.j;.t..t~.. _;r.9..r.~§\l:l........... .Address ................. _.~~.......................................... .. Date of FuneraL .... .naC.e.mb.e.r....2.~ .... J,9..QQ..................Time ................?.. p .• U.
Charge to.........
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Place of Funeral Service..... c.)J.J.y..e.r... ..$. ..
Clergyman.....Tim ... Lar.kln.".Chas.. ,.... y.O\n.«.ansit. .. Call for ? ....;.; .~ .. ~. =.~ C svi l1e
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::::~~~~::::I ::~ o~r~7ee:~.::::~~:::::: :::::::::::::::::::::::::::::::: Shirt, Cellar, Tie .................................... .. ............ Shoes $...................... Hos. $.................... .. Underclothes ........................................... . Door Spray ............................................... . Gloves $.................... Chairs $............ ,...... . F lowers $..................Palms $................. . Cremation ................................................ .. Newspaper Notices ............................. _.. . Telephone and Telegraph ....................... . Ambulance ............................................... . Funeral Coach........................................... . Passenger cars .......................................... 1 Pall Bearers' Service.............................. .. Transferring Body.................................. .. Opening of Grave ...................................... Cemetery Charges .................................. .. Lot .............................................................. 1 Misc. Transportation ............................... . Shipping Charges ................................... . Clergyman ............................................... . Singers $................ Organist $................. . Cash Advanced........................................ ..
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. Pi. Total Amount................................. .
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Remains to be shipped-see reverse for details.
Interment at..............Q.:U,Q....Q.~.m.~.j;.l:l.:r.y.............................................................................................................. Lot No•............................................Section No ............................................ Grave No .............................................. .
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Ramarks ......6-3.5 ...gall.Q.VlaY..... S.t ...e1 ch medium blue sh a ded silver ....... .......................................................................................................
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