Date. ....Al?;r.l-J...•:j,.,•.. J9..Q .l .....
CHECK EACiI ITElII AS COMPLETED
FUNERAL RECORD OF No ........•..................• ......_
Y.arly No ............
?!?.......................
Nam. ...................... N.e.y..e l.. J2;;).1.Jl~.... L.~.l2r..~n9.~....................................................... Sex........ll1~;J,.~........ .. Address ...............................Y{§,.§hp..\lr..n .....MJ .§..~9.~r..~..................................................................................... County....Barr.y.........................Township ...........A.§h .............................. Phone No .....................................:...... . Where Born. ............ B-o,,.LT.Y. ... 'O.O.Un.ty.. .... Mis..SQ.JJ.:r.J........................... Race ............ :\'!p..J:t~....................
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Dat. of Birth. .....J
8.1. ... J ..$.. .... )..9.19........................... Age........................5.g...~...:J,g.................:J,3................. (Years)
How Long Resident in Community............l.lf.e....
(Months)
(Days)
t..i./ll..e...................... ..............................................................
Singl. ........................Married. ....................... Widowed....................... Divorced ..c1J.Y9..:r.g.Ebtild.......................... .. Husband, Wife or Child oL ....................................................................................................................................... .. Address ............. _........_.. _.... _........_...... _........................ _......................__ ........ _. __.............................................. ____ ._....... .
Closest Relative...... Mr.B.. ....C.l£lY.8.... L.awr.eJlQ.!L.......Address ..... W§..§l}.1?!:!r..!l,.. )~tS..S..o.gE.i.... Father's Nam..........S.amuel ...J~L .... La).v.r.arW.e..............Birthplace............................................................. . Mother's Maiden Nam.......Dle.v.a ... Bo..l.e.s. .......................Birthplace..............................................................
Cause of Death ..~...................................ContributorY.~••~~. Date of Death...... ~.r.11 ...l
......12.6.1.................................Hour....... ~ .....:?!:. ..:_;;r.:. ...
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Place of Death ....... h.Ql!le .......................................................... .How Long III ?................................................... .. Physician ..... Day.le....JY.illi.al!lSQn.. .... Q.9J:'9)).e.r. ... Address ..Q§..§.§.YJ1J~. >. .. Jvtl·..~..~.y..!-!:r.:l: ...
Casket ..& ...s.e=.iO.B.8. ..................... 1 (Style) (No.) Outside Case or Vault...... _...................... . Embalming Body ................................... . Professional Service ............................... . Hair Dresser..................... _......... ___ .......... _. Suit or Dress ........ _....................._._..... __... . Shirt. ~. Tie ....UO.d.e.rUZ.e"'U!.... . Shoes $... ___ ._ ... _._ ....... Hose $.__ ... _. _.... _...... __ Underclothes _.... _........ _.. __ ...... ____ .__....___ ___ ._ Door Spray _... _...... __ ..._. __ .......... __.......... _._ .. . Gloves $.................... Chairs $.................. .. Flowers $..................Palms $.................. Cremation ...................... ___ .....___ .. _............. . Newspaper Notices .... __ .____ .. _.. _.. _......... _.. _ Telephone and Telegraph ...................... .. Ambulance ............................................... . Funeral Co.ch ........................, ................. .. ........... . - Passenger car . ..............." ......................... r Pall Bearers' . Service ................................ . Tr~nsferring . BOdY.................._... _............ _! Opening of Grave.. __ ._. __ .____ .. _.....______ ._ ....... .
Occupation of ' Deceased.... -1j'.a,Dffi
~::~~.~~~...~~:~~_~~:::::::::::::::::::::::::::::::::::: 1
Name of Employer ........................................... _... __ .... __..................... __ ........ ___ ...........__ .__ ... ___ .... __ .............................. .. . Address~
Misc. Transportation.----.--........... _.. ___ .. __ .. _r Shipping Charges _........... _........... __ .. __..... _ Clergyman _.................... ____ ... ____ ............... . Singers $__ ............. _Organist , __ .. __ .. __ .... _.. . Cash Advanced._._ ...............__ ..... _............. .
....... _._. __ ... _..___ .__ .. _. ___.___ .. __ .___ ....... __ .___ ... __ .......__ .. _.. ___ ... __ ._ ....................... ____. ___.............. __ ..... ___ .... __ .. _........... _...........
Charge to
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Place of Funeral Servicc..........Cu.hr.e:e.!.. s... ..Gbap.el
............................................................................. _..... Clergyman... B.~.y..,.....f'. ~.r.ry.JU,.g.~lIlg.l1 .......................... Call for? .............. _..........................................._
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Interment
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FUNERAL RECORD OF Casket &....s.e:r.y..lc.....a........................ (Style) (No.)
g9.... _...........
No................................__
Yearly No ...................
N ame. .....................................Nancy ...Er.am:.e.£!. ..La.vI.B.Qu .....................................Sex. ..........f..eJ.Ua.le
Address .......................................Ex.at..e.......... :1.. . ..r!.Q.v.pl .................................................................................... County.....6...r.ry.........................Township ..................................................Phone No ............................................. Where Born.. .........K..ent.u.ckY.........................................................................Race.............y!.f1.tt.e.................... {
Date of Birth. .......F.e.g.r.].!...i1r.y..... D~.... J
§.$..3...........Age...............7..~ ............................................................. (Years)
(Months )
(Days )
How Long Resident in Community .......... __................ ___ ............... _.............._............. ___ . __ .... _.....................................
Single........................Married........................Widowed.... .Y!..:j,g.9.'!!.~vorced ...................... ChUd........................... . Husband, Wife or Child of .................................,A,b.e....L il.mSQ.U ....................................._.................._.............•• Address ..........................................................................P..e .Q.e.
l .......................................................................... Closeet R.lativ•...... Mr.,~ ..<••••G.tu:al. ....6.e.9.K ...................Address ...;.Q.
Cause of Death~ . . . . .. . .. .. .............ContributOry......:.... :....::..................................:..... Date of Death ......@ ....iJ......? ... ~ Ho~r..... ~......!.L!..7..:!L.!.:/......................:.:...:.._ Place of Death.... .9...?t.e.Q2.{l..thJ.Q... J1.
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Physician .........l);r..• ... .l}:.•....E...... Cridling.......................Address.) .g .? .eY.J),J.e .• ......tl,.J!..$.Q'J.r.J.... Occupation of Deceased....D.Q.J.1.s.e.YJ.lf..e..............................Social Security No............................................. .
Outside Case or Vault ............................. .
Embalming Body ....................................
..... ·....·.1Professional
Service ............................... . ............ Hair Dresser ............................................. . Suit or Dress ........................................... . Shirt, Collar, Tie ..................................... . Shoes $......................Hose $...................... Underclothes ........................................... . Door Spray ................................................ Gloves $.................... Chairs $.................... Flowers $..................Palms $.................. Cre~ation ................................................. . Newspaper Notices ............................. _.. . Telephone ·and T. l.graph ......................... . . Ambulanc.· .:................................:...:.:~...... ··F uneral ·Coach..............;·.:...;.:..;::...:..... ::..... Passenger Cars ........... :......... :.................... _........... Yall Bearers' Service........_.............~ ........ . ...:...~ : .. : Tr,!-nsferring Body...................................... ............ Opening of Grave..................................... . Cemetery Charges .................................... Lot .............................................................. Misc. Transportation ............................... . Shipping Charg es .................................... Clergyman ................................................ Singers $................ Org anist $................. . Cash Advanced ..........................................
Name of Employer......................... __ ....__ .___ ......_....__..................................................................................................... . Address ............................................................................................................................................................................. .
Charge to ...........Q):l.;\..ldJ.'.e.1L..................................................A ddress ................................................................... Order Given By..........................ch:l.l. r.B.n...........................Address .................................................................. Date of Funeral... .......!\J;>.r..U ....I±.•.... J.9.6.1. ..........................Time .................f;..;.3.Q....f'..•.M.,........................... Place of Funeral Se'cvj(;e....... (;.u, J."'e;r...!.s... .'J.n.i\p.e..J......................................................... Clergyman... R;"Y..ffiQn.('L.BJ.aC.K::.CJY..Q..e ....i,i.Q.C,Q.rm./.Ja:Ji>-for 1.................,
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Total Amount.................................. ,- -- .Remains to be shipped-see reverse f or details. Information Given To:
Interment at .... _.. _......lla.J::lJ..e.\\lQ.Q.CL..iJ.J'l,!D.!,.:tca.l-::/..............................'!I'~..................................... ........................ Lot No .............................................Section No ............................................ Grave No .............................................. .
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(Boone) CHECK EA= ITEM AS COMPLETED
FUNERAL RECORD OF Yearly No ........_.. _..}.Q....._......_...
No•................................_._
N ame. ...................................MaO'.... Em.mil. ....BJ&f;Jl...... _.................................................Sex..f~!!!.g.J~ ......... Address ................................. _.................. _.................................................................................................,.................... . County................ __ ................. _.......Township _____ . __. __.. __ ..•......................__ ........Phone No. ___________________ .____ .___.............. . Wh.ere Born. ............_........ _............................................ _...... ___ .... __ .. _____.____ ._______ . __ .. Race _______. ________ ... ____ ..___.. ___ ............. .
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Date of Birth. ........................................................................ Age.................. ~2 (Years)
................................................. _....... (Months) (Days)
, How Long Resident in Community........................................... _.._.......... ____ ____ ........ ___.___ .. ____.. ____. ____ ._.___ .__.__ .__........... . Single............_...........Mamed. __ .. __ ................. Widowed....................... Divorced ...................... Child........................... .
Husband, Wife or Child of............................................................... _...................................... _.................. _............... Address ..........•.. _...•...._•. _..••.................................................................................•.......................................................... :
:l:..:....~..:...1?:::E.:.:~~.~..........Address.........................................,........................
Closest Relativ•._...... .!y!.!.:§..:....
Fat her's Name....................................................................._.._••...Birthplace................................." .......................... . Mother's Maiden N ame.................................................................Birthpl.ce ........... :..... ;c........................_................. Cause of Death ...............................................................................Contributoty......................................................... . Date of Death ................-A.p.l"ll ...~,., .....196l
......................Hour..,.................~., .....".6..J? ...iL.~, ........,.......,..
Place of Death................................................................................How Long Ill ?...................................,........... _.... Physician................................................................~ ......................... Address ...................-.........................•..................... Occupation of Deceased............................................................... Social Security No ............................................. . N arne of Employer ........................................... _........................................................................................................... .
Address ........................................... _................................................................................................................................ . Charge to ....................................................................................... _Address ............................................. _................... . Order Given By......................................................................... _...Address ..................................................................
Date of Funeral. .........AQ.:r.il .. .1.•... J3.6.L ........................Time..................?.)'..,.l.!..•.....................................
Casket ... _........................................ :........... $.................. (Style) (No.) Outside C2se or Vault. ............................................... .. Embalming Body ....................................................... . .. .......... , Professional Service .................................................. .. ........... . , Hair Dresser.................................................................. Suit or Dress .............................................................. .. Shirt, CoUar, Tie ...................................... .................. .. Shoes $.....................Hose $.......................................... Underclothes ................................................................ Door Spray ................................................ ................... . Gloves $.................... Chairs $........................................ Flowers $.................. Palms $................................ ...... Crem.stion ................................................................ ..... . Newspaper Notices ................................................ ..... , TeJephone ·and Tel.graph ........................ .................. .. Ambulance •.•...•: .............-............................................ ... ' Fun.ral··Coach.:....: ..........: .....: .....: ..:........... .................... Passenger Ca·rs~:·::.~ ..~·.:·..~:·....... :.. ;................ ... :.......... ~... .. Pall Bearers ~ . Service ..................................... ~...........~ .. Traf!.!3ferring Body....................................................... . Opening of Grave......................................................... . Cemetery Charges ........................................................ Lot ............................................................................ ...... Misc. Transportation .................................................... Shipping Charges ....................................................... . Clergyman ................................................ .................... Singers $................ Organist $..................................... . Cash Advanced ............................................................. .
Place of Funeral Service............. M9.Q!J.e.~n.. _Q .haLl.§.d-.............................................................................. _.. _. Clergyman.......Re.V..•....1'.a.111 ....T.rlpp.................................Call for? ................................................... _......._ Address. ................................................................ _ ..............................._............................._............................ _......_.. _
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Total Anlount.................................. - - - - _
Remains to be shipped-see r everse for details.
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Insurance......................................................................................... F OR M 52.35 SUPER IO R F UNERAL SUPPLY CORP .. CLEVELAND, OHIO.
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6., .....1.9.61
Date. ...•...•.. ..Ap.t'.i1 ....
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FUNERAL RECORD OF Casket ::-.y..?-.1\±.'P.:::.§.El.:r:Y.,;l..Q..l'1 .§........ (Style) (No,)
Yearly N o•....•}.;!-.............................
No................................_._
Name........................................!i'r.ank...l'!eb.b ..................................................................... Sex........ male. .........
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Outsi~e
Case or Vault..............................
Addr.............................................:t!n shbJ.J.ro.,. ... l,U.s,S.O.ll.:t'i..........................................................................
Emball!'!ng Body .................................. ..
County....ll!1lT.Y.. ....................... Town.hip ............l~(~.i?hp.~Tl} ............. Phone No .............................................
Professional Service .............................. .. Hair Dresser............................................. .
Where Born....P.I.l£L..Bidga,...... r.kanS.!1. ....... _ .................................Race....................w.-h.l.-1i!.e.............
SuitJOI':XlXMs .unde.r.clo.th.ing.
Date of Birth.....Al.1g.us.t....25, .....1$J.-7-....................Age .......................... .15}............................................... (Years) (Months) (Days)
Shirt, Collar, Tie ..................................... . Shoes $....... _............. Hose $.................... .. Underclothes .......................................... .. Door Spray ............................................... .
How Long Resident in Community......... s .in&B....l8-lS.....................·.............................................................. Single........................ Marriedill....ar.:r..l.-.e.lWidowed ....................... Divorced...................... Child ............................ Husband, Wife or Child of............................. na. ..:il.a:r..d.l . l"l...•We.b..P........................................................... Addres . ....................................._.... _................................•...y.(!?,.!ill.1?1\£.l h ...Mt.!!..'?Q.~.r.~ ...................................
Gloves , .................... Chairs $.................. .. Flowers $.................. Palms f .................. ;
Closest R.lativ. ............................................................................. .Addres ...........................................: .......................
Newapaper N otic ................................... . Telephone and Telegraph........................ ' Ambulance ......................................:........ . Funeral Coach .......................:................... .
Cremation .................................................. .
......E......1'1.e.b.b.........................................Birthpl.c. ............................................................. Maiden Name····l··· .. ·':t~Sl,.{l.·& · ..p.~·1i.~·~£·§·~·;..·..·.. ·:o:W~Ml·c!f'·anuX'·e· ................·....•..·............··•• Death.....S.e.n.1.. 1 ..y.... ... )I..Q.UKe.i!.. .'..-h.v..e.......Contributory ..................................................... _.. ,
Father's Name••....! Mpther's Cause of
Date of Death... Ap.rJ.l ... 6.,.....19.6 .l. .................................. .Hour.................J.l :;:A:. :....M.:......................:......, Place of Death ........ hQ1Jle.......................................................... lIow Long Ill? ..................................................... Physician......... D.r. ..... .Gb.?..s...... H.....P.r.i.C.e....................... Address ....:....C.a.§.,,:v.:i.1J.e.,....H~L............. Occupation of Deceased......f..:;J,J'.m~.:r....................................... Social Security No ............. .5.QQ:::.L!-.Q::-.5..?.gO
Passenger Cars ...................·...................... . Pall Bearers' Service................................ . Transferring Body......................... :......... . Opening of Grave ..................................... . Cemetery - Charges .................................. ..
Name of Employer __________________________ .... ___ ....____ .__ .. _____............................................................ ____ ......___ ...........................
Lot ............................................................. .
Address ..................................................................... _...................................................................................................... .
Misc. Transportation ................................ Shipping Charges ................................... . Clergyman ............................................... . Singers $................ Organist $..................1 Cash Advanced ... _................................... ..
Charge t o.........f.a.mi.ly. ........................................................... -Address ............................................._....................
Order Given By.................f.amJ.l;)r...................................... _...Addr.ss................................................................. . Date of Funeral... ...... Ap.t'.1..1... ,s......1 .9 .6.1 ..........................Time ..................2...1'....M..,.................................... Place of Funeral Service .................G.iJ.l v .ar..!.. R ... QbJ3,Q.fl.l ....................................................................... _.... . Clergyman .......... Re.JL.....Che.Jil..,....Y.;;mZCan.g:t............... Call for? .........................................................._
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FUNERAL RECORD OF
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N 0 •.................. ....._ .. _ ......_ Name. ...... _............................. .Yl.
Casket ....................................................... . (Style) (No.) Outside Case or Vault .... _______ ..... _...... _....._
r.n .................._.................................................Sex........ .f'.EJ.lll!?:.:),.~...
Embalming Body _ :_: _~-::: .---I P rofessional Ser vice .. ____ ... ___........_.__ ....._.. Hair Dresser.__ ... ___ .. _. __ .__ .. _... _. __ .... _...... __ .... . Suit or Dr ess ._ ...... _. __ ........ _._ ...__ .. ___ .__ .__ ._._. Shirt, Collar, Tic _________ ._...____ .._............ _....! Shoes $......._............. Hose $..................... . Underclothes ... __ ... __ .. _...... _.... ____. ___ ..... _.... . Door Spray _____... _____._____ ._____.____.__ .____ ......__ ..
#1.......~9.~....;t.lJ:lJ:... A ........
County__ ............ __ ...._______..... ______ ...... Township ........___ ... ____ ._____________ ._______________ ..Phone No. __ .............. __ ........._........ ___ ... . Where Born. ...Jla.sh.blLI'n •...Ji
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iaa.our.l.........._ .... _........ _................. Race ... i·/b.i .t .e.............................
Dat. of Birth.........................................................................Age...........2j........................................................_..... .. (Years) (Montha) (Days) How Long Resident in Community.. ____.__ ._____________..... ________________.................. _..... ___.......... ______.. __..___ ._____ ._______ ._____ .__ ..... .
Single........................Married. ..... m"'r.r.),.~dowed....................... Divorced ...................... Child........................... .
Gloves $.................... Chairs $...................• Flowers $...........:...... Palms $................. . Cremation __....... _....... __.___ ... _......_..__ ...... _ .~ .. _ Newspaper Notices .._. __..... _...... _......... _._.. . Telephone and Telegraph ......._.............. . Ambulance ... _......_......... _........_................ _. . ..... 1;,-('~,,~., ~. 1Funeral Coach ...•....... ,= ...''''1'l .~. ,
Husband, Wife or Child of ..............................J.Q.hnm:....Q9..r.n ......................................................... _............... Address .......... __._........__._ .... _............ __............. _................. __ ..______ .__... __ .. ___________... ______________________________________________________~.- -- - . Closest Relative.........,l..Qhun:i....C.Qr.n................................Address ..................................... ': .. 7 •••••• • ••••••• ••• •••• ••
H.e.nr.:v....................... _.. _.....Birthplace.................................•........._.......:......... Mother's Maiden Nam•.......1Li...gJ...nia....S.t.JJ.l .............Birthplac •... _...................................... _...............~.
Father'a Name..... '/l.il.Ll.r.d ...
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Cause of Death ................•..............................................................Contributory......................................................... . Date of Death ...•......-1l-p..:r.JJ....
Passenger Cars .......................................... \
!±.,....J9..?.;\-..............................Hour........................................................................
Pall Bearers' Servic •................................ Transferring Body................................... . Opening of Grave __ .. ___ .. _. ___ ... _...... ___ .......... . Cemetery Charges. __ .__ ... ___.. __ .. _______ ._. ___._._. Lot ............................................................. . Misc. Transportation.... ___ .. ___ .. ________ ._ .. _.. _.. Shipping Charges .... _......... __ ...... _______ .___ .. _ Clergyman ___ ._ .. _____________ .. _._. ___ ............. _.._.. Singers $___ ..... __ .. __.. Organist $..........____.__ . Cash Advanced.. ________ . ___ ..________ .______ .____ .._..
P lac. of Death ........C.O'llllI.:a~.> ....Ark....................................How Long Ill ?................................... ................. P hysician ______ _____________________.__ ._ .... _________. ___ .__.__ ._______... _._._______ ..... _._. __.Address. __ ...._.... _...__. ___ .._._. ___ ._._._._ ._......... _. _____________ _ Occupation of Deceased___.llQllS.e_y.Iif_e__________ ____.___ __________.Social Security Nc. ___ .. __ . __... __ ____ .___ .__. __ .__ ._________ ... Name of Employer_ .. _..... _. __.______. ____ ._______ .__..___.___ .. ______ ..._._._ ...._._.. _. __.. ___ .. __ ....... __ ....__ ._. __ ... _. __ ._._ ... __ .. ___ .. __._.__..___........_._.. Address ________ .___ .._.... _.. _... ______.. _.._________ .. ______.___ .__.. _...... ___.____ ._ ..______ ._ .. _.._..... ____.........__ ... _........ __.. _. ____ ._ .. __ ._____________________ ._____ ..
Charge to ...........b .u.\!b-ar.ld....................................................._Address .................................................................. . Order Given By.............ffiQ.the.r.....a.lld...f .a..t h.e........ _...Addreas ..................................................................
Date of FuneraL. ...A.Q.~tJ.... Place of Funeral Service._.__ ...._...._.D_ l ll
9.•....J.9..9J ..............................Time.................
Clergyman.........B.e.y. ......RQy....i31.L:Lliyau....................... Call for ?................................................... _........_
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Remains to be shipped-see reverse f or de-tails.
Interment at...............Kt.!}g§....Q.~ .Ill~.~..EJ.r.y......................................................................................................... Lot No. __________.. ____ ......... _... __ ._..___.__.. _Section No ..__ ._. ___ ____ ._____ .__ .. ___ .. _________... _.Grave No. __ ._...________ ._______.___ .___ . ___________ ._.
R,. rn a r k' ...............N.n .9:[email protected] ....§.1;g~).....l . Clh .:....J .t. ...1?)1,l.~. ......?JJy.!?r......@..?._.90~.g....... ............... ..... J.y9..r.,y.....?;3,.~.l] ~IJ:t}:l ... 1;lJ.ll,~.....fl.?-.~<:lP... .:f':lJ,:L .. 1':r:~.l!l .. ...... .............. .......... ............................ C.Q.nne....$.:v:J.n!il....G."'.~1l:.~.:t .. Qg..! _ .._ .•................ . . . ...... ............ ...•.... .... . ............• FORM 5ZS!' supeR I O R FLJN.ERAL SUPPLY C ORP .• CLEveL A ND. O HIO.
D Lodges o Pall Bearers
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Information Given To: o Relatives o Musicians
D Clergyman Singers
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Attended To : Death Certificate Payment Arranged
D Permit Bill Rendered
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Insurance_ .. _.__ .......... _..._. __ ................. _.__ .......... _....... _.. _.____..____ .. _____ ..._
CHECK EA= ITEM AS COMPLETED
FUNERAL RECORD OF
,
Yearly N 0 ........3..3............ _...........
No..................................._
Outside ca:~;;;e~ault......... (.~~:)............ 1 Embalming Body .................................. ..
Name. ......_................. Mar.y.....El.~.;;.~.Q!2.th.....+...~.gg~?}:y.!.9..Q.Q...................................sex........ .f..~.mf.!,JsL. Address .................................e.0.:~..~.~....!~A.O'.~.L},~:i.~.:s..?:u.E.~... ..........................................................................
Professional Service ......................._...... __ 1 Hair Dresser.............. _...........__ ................. . Suit or Dress ............. _............................ . Shirt, Collar, Tie ...... ___............................ . Shoes $......................Hose $.................... .. Underclothes ........__...... _...................._..... _ Door Spray._..............................................
County.....12o\T.T.y........................Township ..~h.
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Date of Birth. ....... .s.e .p.t .embe.r.... .8.•.....lS.S.6..........Age ........._...........7.l±............................................. _....... (Years) (Mont hs) (Days) How Long Resident in Community.... __ .... __ .... __ ..__......... y..e.ar.
.............. _.__........"........ ____ ..........___.........................
Single........................Married. .. mar.:r..1.e.\Widowed .......................Divorced...................... Child ........................... . Husband, Wife or Child oL ........................Gr.O.Y..er. ... L.e.dgarJ!!.O.n.d .................... _.................._............... Address ............. _............ _........_................................§h.eJJ... :\\.!l.Q.p..Jt.....MJ.(L~.Q_lg:J....................................... Closest Relative .......[I;J:g.y.§J:... J,;!2g,gg.r.X!g.Q.Q................ .AddreS8..........................................,. .................... .. Father's Name..... J.iIl.T.IDg.!l.. J.tl·.t.§ID.\l,.!L .................... _.....Birthplace.............................................................. Mother'. Maiden Name... _..P..§J.l~..J1.1l.~.§T........................Birthplace... _.................. '1'....................................
Cause of DeathQ.!;',.f.~P.f.f!,..\ .....~."~g,~\.,,s... A.r.c.,..~~t.ContributorY....Ij.~lfe.r.:i>?!).~.L~.!?....cl~:d. Date of Death..._.,M.r.JJ.... 9. ......l9..Q.l ................................Hour ..............,$.,:::i..~..f.:.:m .. ,............................ Place of Death ........h .Qffi.e ..........................................................1-Iow Long Ill? .... Physician ......... Dr ......
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Casket ...&....S.e.:ryt9..e..S.................... .
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.v........E.. ....C.r.l.d.ling...................... Address .........C.aB.s.v..i l l.e .. ....MiS.£IQlU' i
Occupation of Deceased.......h'O::J.s.erLif.fL ..... _............._.... Social Security No ...... _.......... __ .......................... . Name of Employer ........................_............ _....._..... _..... _...................._....... _.... __........... _......... _...................... _.... _.......... _ Address_._ ............................_............__ ....... _..........................................._.. __._ ........_................_..... _.....................................
Charge to ...............G.:r..Q.ll.e.:r....Le.dgep"rQ.Q.d....................Address ........ }3h.Sl.l .1 .. KD..Qp....... ~ .11HlQ..\lr i Order Given By.......... !~_ .... _.._........._ .....~!_ ..... _..............._.......... _._...Address._... _..........._................................................ Date of F ulne:'al.......... J~pr.j. ~ ... .!.~ .,' .... ~~!.o ..L .......................:rinle ..........................c....~..•ul .................................
Gloves $.................... Chairs $.................. .. Flowers $.................. Palms $................ .. Cremation ................................................. . Newspaper Notices ................................. . Telephone and Telegraph ...................... .. Ambulance ................................................ ' Funeral Coach ............................................
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Passenger Cars._ ....................................... . •.......... Pall Bearers' Service................................ Transferring Body........... __ ....... ........... _.. . ............. 1qpening of Grave.. _.................................. . Cemetery Charges ......................_............ . Lot .............................................................. Misc. Transportation .........._..... _......._....... .. ........... 1 Shipping Charges .................................. .. ........... .. 1 Clergyman ............. - ................. -...........-.. . Singers $................ Organist $................ ..
_.... ....... 1Cash Advanced ........................................ .. .8."'J.p,.s, ... 'I'.?-,X....................................... .
P lace of Funeral Servi,ce..........);m.!~.".±.. Ji.J:\.~cQ.....',<..m n':gn,... 5?I ..... ,!.g .!.:J&:L ........................ ..
Clergyman... Bro. ... C.line... Hgr>..c.ClCk ............................. Call for ................................ ..
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Remains to be shipped-see reverse for details.
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Interment at.........P.a.in.t.e.r. ... C..emat.eTy.....................................,..................................................................
D Pall Bearers
Lot No ...._..._..._._ ...._.........._............. Section No ......... _.................................. Grave No ......... _.... _.... _.._..............._..._... . R, m " r k . ........................N.ll..Q!..Te,ga J .... g.g.r.ll; ..,g~nm!2.t.~l:::Jl.:\.. ly.t;1.r:.... §.t!.;:!.<;jJe,L.JJ.t.S'..~J.
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Clergyman Singers
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..............................................C.Q.nn.erE.v..ille.....C.il.,Sll:.e.:t._ ..C.Q.......................................................................
Insurance ..................................._...._........... _......._....._............._........_
FORM 1323 5 SUPERIOR FUNERAL SUPPL" CORP • . CL.E\l EL.A NO, OHIO.
Death Certificate Payment Arranged
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Pennit Bill Rendered
184 Date. ......t.pri L lQ,.....19.6L
CHECK EA= ITEM AS COMPLETED
FUNERAL RECORD OF Casket
Yearly NO ..............)& .....................
No ................................ __
ry...... " • .l a"'.9.:t.e......................................................... Sex. .... .rIl?-.;L..~............ Address...........................................§,.J:'l~ S\;t\·....KnQ.1?.,........~. fJ..s.9..~E.t .................................................................. Name. ................................... H
County..... E.a...r.r.y..__ .. __ ...______._...Townsbip....... ______ ... _... __ ....................__ ....Phone No •........................... _...........__..
e.ll... KnQ.h.,.... \ .L5.S.Q.l.tr.1................................. Race .......... Ylh.:tte...................... Birth.....J . ne....19.,.....1 .6.6.......................... Age............zl±................................................................
Where Born. ...........5L Date of
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(Years)
(Months)
(Days)
How Long Resident in Community...................l if.e ....t .ime............................................................................. Single.......__. __.. ___ .......Marned... ______ .__ ._______ ... _.Widowed ...~.~.~9.::~.~.4ivorced._._. __ ........ _ ......Child............................ Husband, Wife or Child of.. ......................... E1.l.D.ic.
....~l.ilJ.s....dpp.le.g.a t.a .......~........d ..c.e.as.e.d
Address ............................................................................................................................................................................ .. Closest R.lativ.....1!.r.s......D.Q.n,,',....R~.gJ.n
......................Address..........~.~.;L..:),....~.!}9.p...t ....M~.~..s.9.~r i
Father's Name......J .O.e ... l\.Pp.leg.at.e................................Birthpl.ce..:........................................................... Mother'. M.iden Name...... J!Jlar.t.h .....,J.!illi!.!U:l...................Birthplace..............................................................
C.use of Death ........ Q.~E.!?!2.!.'.§:;L. ... !:!.~.!!!9..:::~~~§z.~..........Contributory.....................................:.................. .. D.te of Death........~P.E:P:
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Occupation of Deceased_____ f..a.r.rn.e.r. .. __ ................................ _Social Security Nc ............un
(Style) (No.) Outside Case or Vault............................. . Embalming Body ................................... . Professional Service ...................... _____ .... . Hair Dresser............................................. . Suit or Dress .......................... __ ......_____ .___ _ Shirt, Collar, Tie._ ..................... __ .__ .__ . __ ... . Shoes $......................Hose $.................... .. Underclothes ........ __ ......... __ .. ____ ..... ____.___ . __ _ Door Spray ........ ____ .......... _.......... __ ... _........ . Gloves $.................... Chairs $.................. .. Flowers $..................Palms $................ .. Cremation ......... __ ........................... ___ .___ .. __ . Newspaper Notices .................................• Telephone and T.legraph ...................... .. Ambulance ............................................... . Funeral Coach ........ ::..................................1 Passenger Car.;.. ::..;................................. . ...._....... Pall .Bearers' Service ............................... . .. ........_. Transferring Body................................... . Opening of Grave .......................... ___.___ .__ , j Cemetery Charges ................................... . Lot .............................................................. Misc. Transportation............................... . Shipping Charges ................................... . Clergyman, ............................................... . Singers $................ Organist $.................. Cash Advanced .......................................... .
............
....~9..!...J~.§.~.........:...................Hour.:......:....:.ll.;,5.Q... I'....a. ..............:.........H.
Place of Deatb ...... S.:t..e.lltL.H9:p..!?H...J. ........................ .How Long Ill? ......... hx.§............................ Physici.n... .D.r..,.....(L,....A., ....f')J.r.y.~.§................................... Address ................g.~.s..s.y..:i..:),.~.~.L.lii.*.S...~
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Name of Employer...... __ ........................................................................................._.......... _........................................... . Address ... __ ... __ .... ___ ........... __ ....... __ .. __ .__ .. ___.. __ .. __ ... _........... __ ._ ...____ ................................_.. _................................................... .
Charge to ......... faml1:y: ..............................................................Address ................................................................. .. Order Given By................. f.amll:y: ..........................................Address .................................................................. Date of Funeral... ....... Ap.r.il ....16.,.....1:;l.6.1 ......................Time ...............2..:.3.'O... l'....J>1. ............................. .
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PI.ce of Funer.l Service ........... Sh..:Ul... K.nQ:R....Q .h!J.r.,gh.....QJ.... Ql:ll:':h.El.1;.......................................... Clergyman ....Br.Q... ....C.line... ,KBnC.QCk ......................... Call
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Total Amount..................................! Remains to be shipped-see reverse for details.
Information Given To: 0 Relatives 0 Musicians
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Lodges Pall Bearers
............................. ..11.2.3.....lt.Q1JJ.~... Q.J:'9..~ .. ),!9.h\.:r.J~...!:I),,:t.J:.1 .. 111().:tj,f.................................
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Death Certificate Payment Arranged
...............................
Insurance ..........................................................................................
Interment at. ......_.._.p-.. 1l,:l.t.e.J:! .-C.eJ~
e.t ...r.iJ"-.................. -_.........•...... __......... _-.....-.-_ ....._..•..... -..................._.... .
Lot No .... _... ____________ ......__ ....___ .... __ .__ Section No .................. ____ ... __ ._________ .... __ .Grave No ......................................... ___ .__
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FORM 5235 SUPERIOR FUNERAL SUPPLY CORP., C1.I!:VEL.ANO, OHIO.
Attended To:
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Clergyman Singers
Permit Bill Rendered
J.L ....;!..9..§1-
Date. .........f..IU:'),J,...
CHECK EA= ITEM AS COMPLETED
FUNERAL RECORD OF No................................_ ._..
Ye."ly No..............
35.....................
Casket ........................................................ (Style) (No.) Outside Case or Vault.............................. E mbalming Body ................... .............. .. Professional Ser vice ............................... .
Name. ........................................Ann.a....Eag),,~.§.Q.n .......................................................... Sex....r~.!11§,J.\l........ Address ................................................. .KanS.:Hl....C..l .ty.. .. ..!t;.;i..R.!?.Q.!dJ.:i ........................................................ County................. _.......................... Township ................. _................................Phone No ............................ _............... D.t e of Birth. ........................................................................ Age .............?.$....... ....................................................... .. (Years) (Months) (Days) H ow Long Resident in Community.............................................................. __.. _..... _... _._............................................ .
Single........................ :Married........... _....... _.... Widowed_...................... Divorced ........_............. Child............................ Husband, Wife or Child of.......................................................................................................................................... .. Addr ess ............. _............ _...._................ _._....................................................... _......................__ ...................................... .
Closest Rel. tive.....Mr.a.A ....GJ.en ...ta.a~e.y.....................Addr ess .........................................~..................... .. Father'. Name................................................................................Birthpl.ee............................................................. . Mother's Maiden N.me.................................................................Birthpl.ee.................. ;........................................... Cause of Death...............................................................................Contributory.......................................................... Date of De.th ...........A2.r..i,J...
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E:~~~;~i:~;,>·. ··::.::::·::::::.:.:::.:. ::.:::1
Wher e Born... ...................... _...................................:............ -............. ;..................... Race ............................................... .
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Sh oes $...................... Hose $...................... Underclothes ........................................... . Door Spray ............................................... . Gloves $.................... Chairs $................... . F lowers $..................P alms $................. . Cremat ion .......................................................1 Newspaper Notices .....................................1 Telephone and TeJlegr.l',h.......................... 1 Amliulanee Funeral \)ol.en........ " ,,, ...-<)..,,....."'.. ,'.............j • .... ,..... Passenger u.:r .............;.............;.................1 p.n Bearers' " e'm .ee ..................................1
Place of Death................................................................................ .How Long Ill? ..................................................... Physician ____ ._ .............. _.......__ .. _......................_. ___._ .......... _.... _......__ .. _.Address .._............... __ ......_._____.. _...___.____ .__ .. _.. _...._...._. Occupation of Decev.sed. __ ...... ____ ... _. ___ .. __ .__._...._. __ .... ___.................. Social Security No .._...... _....... _._......................... . Name of E mployer. ______.. __ .. ____.____..____ ..__ ._____ ._.___..__................... _........___ ........... _................... _____ ..... _. ____. _______ ._ .. __ .__ ._____._ Address ..... _.. _. ________. ____ . ___ .... _.. ___ _..._............ _._.........._._............._................ __ ........................... _...__ ............. ____ .. __ ......_.. ___._.__ Charges ......... '''' ........................ .
Charge to .._... _____. ____ ._._. _______ .. __ ... _.......__ ............... ... _..__._ .............. ____.Address_ ..... _................................_...................... _... . Order Given
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.........................A cldr·~s .......... .... ,c ... ~ .... :................................. .
Date of "·UlaeraL .......... ,""''*.~,.*- : .. ",.L.'.....'''_l.>i.'''.: .....:..... :~.: .... l.·,m: ...................
$................ Organist $................. .
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',!:"'..!" ,,.,'.!.!.... f'.tiid..~~..!,.:?.,'.... ::,.~:.':' :!::.~:"."............................ ...............;
Place of Funeral Service.......
Clergyman ......R~.Y .......A);)....EQ,.t~:=.:~g,.:),.:t;.?.r.. JJ.~§,.\';..... C.ll f or
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Remains to be shipped---see l'everse for details.
Interment nt ........................V.1n.e y....C..~m.~. t.S1.:r.Y................................................................................................. Lot No. ___ _................ _._ .... :..........._...... Section No .... _.__......... __ .___.__ ..__..... __ .____ .. Grave No.._______ . ___ ...._..... __ .. _.__ ._ .. __. ___ .... _.
1<' o;>m :< r k' ------.. ----••....••....•.-..•.. --.. ---. -.-.--... --.... -----.------..--.-.-----.. ---.--... ----------------.----.-.--.---.-.-----...---..•.•...... -...•.......-.-.... --..-..
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Attended To:
Insurance....! F O RM !l2.SS SUPERIO R FUNe:RA L SUP PLY CORP •• C L E:VE: L ANO , OHIO .
Information Given To: Relatives Musicians
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Clergyman Singers
Permit Bill Rendered
186 Date...Ap..r.11.....ZS.•.. _1.9.6..L
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CHECK EACIT ITEM AS COMPLETED
FUNERAL RECORD OF Casket .:-:.Q.. ,.....l?9.~:::.§y.t..'t;.::.............. (Style) (No.)
Yearly No •... _...•.. _36 ...•.......... _......_.. .
No............_.................._._ Name....... _...............P.g.!:l.
.....E-.QJ?~ .................. _................................................. Sex. .... E.1.a;!&........... Address ..........................:!!.0:.§gp..l!·.r.:!:l.L...I:!.~ .~.~.()y.r..~.................... ..................................................................... County....Jl.g.!.TY....................... Township ......._......................................... Phone No ............................ _............... Where Born............~1g.§h9.g.r.n• .....!)J§..2Q.',!.J:'t .. _..................................Race.................,·.! h.;i.J&..............
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Date of Birth........J:1ay.....13.,....1.9.lJ.J...........................Age...................1.-.2........ ......... _........ _.................. _....... (Years ) (Months) (Days)
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Outside Case or Vault __ ........_______.____________ .
Embalming Body .................................... 1 ___ .____ .... ) Profess ional Service ._ .... _. ____ ._____________ ______ Hair Dresser_______ ...._._ ........ __ ........______ _______ _ Suit or Dress _____ . ____ ._ ..__ . ______ ._ .. ___ ......... _.... Shirt, Collar, Tie_ .............. _.._______ . ______ _____ _
Shoes $...................... Hose $..................... . Underclothes ____ .______ . _____ . __ ... __ ... ____._. ____ ._. __
How Long Resident in Community____________ .._........ __... ____ ..... __ ._______............... __ .............__ .___ ...._............._... _. __ .. _.... __ ...... .
~~:~~::~:~.:::::::::::::~~~;;~..$:::::::::::::::::::: I
Single...5.ingJ..e.. Mnrried. .......................Widowed.......................Divorced...................... Child........................... . Husband, Wife or Child oL ........................N.e.,lJ.Q....RQ.s.!O.... _........ _............................ _.................. _............... Address ............._........ _.............................................. :!{,§".?hp..lJ..r.n.,... JJ..t '?.§.Qid.r.L ......................................... ..
Flowers $.................. Palms $................ .. Cremation ................. _................................
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Closest Relative.......~L.ll.Q...Bo..s.e.......................................Address ..........................................; .......................
Newspaper Notices ..............._............... _..
Father'. Name......t:!.IlJJ& ...!19..?.Il..........................................Birtbplace............................................................. .
Telephone and Telegr.ph........................ Ambul.nce ............................................... . Funeral Coach............................................ 1 .P assenger Cars .......:....... _._ .. _.................... .
Mother's Maiden Name....Q:~Qn~1!?:... 9.r..1?.~.!:\.. .................Birthpl.ce ............................................................. . C.use of De.th .....C.Q.!:l.8'.§.,:l.t.t.Y.!? ...h.:i.a.r..Ji.... fgJ.lgr.C-ontributory........................................................ ..
Date of De.th .......AP..r.)..1....?5.,.~ ....~.9..!?.L .......................... Hour.............. .6.~.;i.D. ... A . ....IiL .......................... Place of Death ...S.Ji..,.....y.,;!..!1.Q.\l.nJi..$. ... .H.Q..$.p.J.Ji..'1 J......... Jfow Long Ill? .................................................... Physician ... P..r..,... JL....!:!.,.....f'.r.J.Q.()....................................... Address .........g.~.i?.§.\T.. J,il;i..!?_\l..Q.V...r i Occupation of
t1.J.§.1..... Deceased.... J,aP.Q.:r.\l.r .................................... Social Security No ........LJ:9..9..:-:.Lt!±.::.5.i;.9..?...
Service __ __ .... ___ .._.. __ . ~........... . Transferring . Body________ .~- ------ _______ .... __ ..... . 1 Opening of Grave..... _. __ .________ _____ _. __. ________ ._ Cemetery Charges ____ .__ ._. __ ._ ............... _......
...........
............. 1 Lot
Address... __ .. _____ .____ ........... __ ....... ___. _____ . _________ . ___ . ___ ._ ... _____ .. _. ___ .___ .. __... _____ ....................____ .... ___ ............____ ._._................. _...... .
. ............ 1Misc. Transportation______ . _________ ..... ___ .__ .. _.. Shipping Charges ...... _... ___ . ______________ ... __ ...
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Clergyman .--.....--.... -.----............... ---.. -------Singers $____ ............ Organist $____________ ..___ _
. . . .... ~=:.;.~~::::::::::::::::::i Total Amount. _____________________________...
Remains to be shipped-see reverse for det ails.
Interment at._........_.KiltgS. ....G.p...rna.t_e.r:y_. ______________ .. __ .. _. ____ .. _._. ___._ ..._________________________ ...____ ... __ ._____........________ .. _. Lot No ...._. ________________ ... _._ ........... _____Section No. ____ ____ _.______ ___________________ ... _.... Grave No._............_.........._......._........ __ .. .
R,·m ark ..........................#22'O....... BllJ.,@ ... s:':l,"'d.e.d ... silvPv.r ................................................................... ..
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...... ............ . ...............s.P..r.:~.~f,\t~e.~
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Name of Employer._._____________________ .._._____._o..... _._ ........._...... ___._ ........._......._...........................................__ .._._ ..•................
Charge to ............... ln.!?g .. ..
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Musicians
Attended To: Death Certificate Payment Arranged
Insuran,
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Relatives
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GHEen: EA= ITEM: AS COMPLETED
FUNERAL RECORD OF Casket" B.Q.~.:::AIJ).Q.\J.J!!.Xl.QJL .......... .. (Style) (No.)
Yearly No ..........31............ _...........
No.................................._
Name. ................................l;)O:Q.1;.y: ...Q-.€l-r.liil•..-ll-"'k;iil.::;'·····..·············································....Sex. ........I)f.~Jl? ......... Address ....................................Ex.e.t .e.P-.,.....M.i..$..§.9.ur..L ..................................................................................... Count y....J?.fi,ET.Y......................... Township ..................................................Phone No ............................................. Where Born. ......... .I4Q.D..e..t.t .•...JJis..?9..\!·J:.~ ...............................................Race....................:7.1:t.P:-.~.~
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Outside Case or Vault...................... .
Embalming Body ................................. ..
:::::::::1 ~:~es~~e::~r~.er~ic.c.::::: : ::::::::::::::::::
............ Dat e of Birth. ....AP..r..U ....£'.~L.: ..J.9.QJ....................... Age.............................................................................?... day & ........... (Years)
(Months)
(Days)
Suit or Dress .......................................... .. Shirt, Collar, Tie ..................................... . Shoes $...................... Hose $.................... ..
Underclothes ....... .CJ.:L.Q.~l:tJnK ....... ..
. How Long Resident in Community__ ....__ ......................................................-..............__..__ ................................ _.........
Door Spray ............................................... .
Single........................Married._ ...................... Widowed.......................Divorced ...................... Child.......9.J.J..il£l......
Gloves $.................... Chairs $.................... Flowers $.................. Palms $................. .1 Cremation .................................................. 1 Newspaper Notices .................................. 1 Telephone and Telegraph....................... . Ambulance ................................................ Funeral' Coa·c h............................................
Husband, Wife or Child oL.....................C .l .in.t..Q.n...BJ:ls....lh "e.:r......................... _.................._............... Address ....... _.... _........ _........................................g:.?i:.~.~i£.l .....!!~:1:.?§!?..~~.L ....................................................... Closest R.latlve.......Q.J.;i.r.t!i9..u...B,;LY.....l?.i1';.~.r. ................Address ..................................................................
Father'. Name.........g..;I,.:1:!.!~!?.!); ... B.?:Y.....!?..::~.~£
................Birthplace.....................................:........................
Mother's Maiden Name.... f,!.hJ;;t;!,~.Y. ....Anr.l....!?Q?i:.............Birthplace ............................................................. . Cause of Death ...............................................................................Contributory .......................................................:...
Passenger Cars ~......................... :.......... :::.~: Pall Bearers' Service;.......',..;.. ;........ ;.;..... . T;ra:nsferring, Body......_.......................... .. Opening of Grave.............. :....................... . Cemetery Charges ................................... . Lot .............................................................. I Misc. Transportation ................................ Shipping Charges .................................. .. ..... Clergyman ......................................... ..... .. Singers $................ Organist $................. . Cash Advanced ......................................... .
Date of Death ..........AP.r.il ...2.6, .... l~.61...........,..............Hour........:..... ;;" ..!.;5,Q... l2.•.lIL.................."..:.::
:~:~c~:n~P.'~:':: ·.~:~.~f~·.~.~;:.i!.·.~:~:~:~ ·: .~:::::: : ::.:.: . : :..:~~:~:~~. $~1~:i.~gfi~:~~:;·: ::~ii::~::~::::
... Occupation of Deceased............................................................... Social Security Nc ............................................. . Name of Employer ........................................................................................................................................................ .. Address ...·...........................................................................................................................................................................
Charge to ............:;.l.1..'1trln .. .E\ay.....Bake.r........................Address ................................................................. .. Order Given By............................................................................. .Addres'5 ................................................................. .
Date of FuneraL. ...... APr.1L.2.9...... ~9.61.......................Time ........... J ...P.•.,J,1.......................................... Place of Funeral Service.......... Q.\).lll..e.r ..!.,S,....Chap.e .l ............................................................................. _..... Clergyman ... ...B.(2,Y..:.... .Q)..:y:g.(2....M9..O'.Cl.rm.l:g.K ............... Call for? ............................................................_ Address. ..................Ex.e.t.P..J2.,.....r;I1.::.R.Q.1)•.r.i ....... _.........._......_.............................._.................... _...... _......_.._..
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D
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T otal Amount................................. .
Remains to be shipped-see reverse for details.
Interment at............... Jl
.1egI.o.o.d ...C.e ..e.t .e.r:y. ...........................................................................................
Lot No .............................................. Section No ............................................ Grave No .............~ .................................
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Lodges
D Pall Bearers
Information Given To : D Relatives D Musicians
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Clergyman Singers
R < mar k . .........................?I.... pJ.1l~ ....©.1I1R,Cl.f?..? .El.cJ.. ...Cl: Q.€J................................................................................. wh ite satin hTill interior ................................................................................ _......................................................................................................... ..
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...................... ...... ..........13I3.t:l::::~!.El:.1. ...gEl:.!l~.€J.~ ...g.().... ... ............... ......... ......................................
Insurance..........................................................................................
FORM 5 235 SUPER I OR FUNERAL SUPPLY CORP • • CLEVELAND, OHIO.
Attended To: Death Certificate Payment Arranged
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Permit
Bill Rendered
.. ................................... ........................................... ... .. ..................... ..
