Date. .. _...Q~6..~..
J.....Ntf.L...
~S7\
(Boone)
CHEe" EA= ITEM AS COMPLETED
FUNERAL RECORD OF Yearly No.... _...•.. _....f1!lJ:L-'?..~
N 0 ........................ _ ••_. ____. _
Casket ........................................................ $.................. (Style) ( No.)
C•....I4 ...........ijJ~...-................................................ Sex...!!!q)~............... Addxess .................................................... _.......4?!!1f.. f?.'?f!,%...L4/P1!!W!-................................................... Name. ................................................
County____..... ___.. __ .____ .... __.. ___ ....... ____.Township ................. _________ . ______ .______ ....... __ Phone No ..........__ ............. ____ ...............
Where Born. ... ________ ........_..____...__............. ___.......... __.. _____ ..____......_......... __ ................ Race.................... __..........................
........··.·1
'l? ......................................... __ ................. . (Years) (Months) (Days)
Date of Birth......................................................................... Age.............
Shoes $...................... Hose $......................................... . Underclothes ............................................................... . Door Spray ........................................................... :.. .... ..
How Long Resident in Community__ ..........................:.............................................. ............__ .............. _.... _......... _.... __ Single............__ ......__ .. Married......................... Widowed ...................... :Divorced ......................Child........................... .
Gloves $.................... Ch. irs $.. ,................. .....:.......: ...... Flowers $.................. Palm. $..................................... .
Husband, Wife or Child of............................................................... _...................................... _.................. _............... Address .........................................................................................................................................." .................................. Closest Relative......................................................:...:.••..:......•....•.Addr •••..........•....:..... :.......:..•.••..:: ..:.:.....................
Father's Name......................._.............................:..:::••..•:.~:~ .........Blrthplace..•_........,.•.....:•.•.•.•~••~ ............................. Motlier's Maiden ·Nama.......:..........-•......-:......•..............•.................Birthplace ..~ ..... ;..••..••i •• •• • , ••• ; ... ... ' •• , . ... . . ... . .... ..... ..... Cause of Death............•......................•..............•..:.. ::•.•::•. ::::.::::...:.Contributory.:.:................::.:: ...............::................ 5~emb€/L
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Cremation ..........~...................................................... .... ..
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........ ..
·Funeral" ·Coach .............. :.-.. ....... ~ : .............~ :... :.::: ............... .
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Lot .....................:...................................................... ..... . ·Misc. Transportation................................ .........~ ......... . Shipping Charges ...................................................... .. Clergyman ................................................ .............. ...... Singers $................ Organist $................... ............. ..... . Cash Advanced ................................................... ;.... ..... .
··Address .............................................................................................................................................................................. Charge to ....................................................................................... _Address .......................................................,.......... .
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::.......Total :.:.....:Amount :............................................... ~............ .......· ··:· ~·I············ :::::: I -- - - -
Remains to be shipped-see reverse for details.
Interment at.........................(lJf{I], f:&!f ...db~
...g;m.~J................................................................................
Lot No ................................. __ ..........Section No ............................................ Grave No ........................................... =...
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Newspaper Notices .•...:,....,......................... .................... Telephone and T.leg:..aph ........................ .............. ...... Ainbulance ...........:...:......... ::......:........:...:: ...................•
•••·......0.' ··Passenger Cars:.·..·;~:;·~ :::............................. ................... . ............. Pall Bearers' Service ..........-...................... .................. "
Name of Employer ........................................... _........................................................................................................... .
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Outside Case or Vault.. ............................................... . Embalming Body .................. ............................... ..... . Professional Service ... ................................. ..... . Hair Dresser............................... . Suit or Dress ............................................................... . Shirt, Coll~ r , Ti e ......................................................... .
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Information Given To: o Relatives D ' Musicians Attended To:
Death 'Certificate Payment Arranged
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Permit Bill Rendered
Insurance......................................................................................... . FORM 523!5 SUPErflOR FU N ERAL OUP P L.Y CORP .. CL. EV I; I".AND . OHIO.
Oc:hJbe/l. 1961 Date... __........... ____ .__. __ .. ____._2~_....... _..._...
CREe;.;: EA= ITEM AS COMPLETED
FUNERAL RECORD OF Yearly No •..........._.....mj.{?~..
No........................ _........__
Name. ..............................!S.rd~ 5..i;.~ Sex...j:.WlI.d........... f{, {.LV. fIli.Mo . Address .................................... ~... L:: ....~..................~............................................................................:.......
..
Where Born. .... __..... __.___ .. ____..... ___.________...___....................... _____ ._____. ___ .... _____ .___ .. _______ _.Race.__.____ .____________ .. _______________..... __ .. _
.. ..... j Professional
Service ..........
-0
....... .. .. .
.. .... .
:~::::::::::I ~~::~ ~.~~.l.~~~..~.~~~~~ii~·~~··$::::::::::::::········
How Long Resident in Community................ __.___......... __ ....__ .____.................. __ .............._..__ ..........................................
Underclothes ........................................... . Door Spray ...................:.......................... ..
(Months )
(Days)
Single........................ l\rlarried ....................... Widowed ....................... Divorced ...............,..... ,Child....,........................·
Husband, Wife or Child of............................................................... _.........................................................._............... Addr.......................................................................................................................... ,.,.. ,.....,...............~.............. ,... ;,;......• Closest Relative.......................................................;; .....................Address ..... ;; ..................... ;............~;.. ;..... ;;•.. :........
Father's Nam$..........•........•......•..•..............•......•..~:·.:.:..• ;.........~ .....Blrthplace..:..•.....•••.·;.....·............... 1;.·. ·. ....... . .............. : -Motlier's--Maiden
Name..........................,.............,...,.........,......,...Birthplace.;:.. ~ ..·~~~.:.•.......••.~i. .............................,.....
Cause of I!eath ........................•...................•..... ".::~.:~~::::~:~:.::;~:: ....Contributory .... ,;;·, :-.~~.~ ..... :: .•..~ ..•~~,.,~:,~:~ •.. "';.•• " .••.•.
Date of Death .... .QrtR/2.~ .. .?"....
.t.9.6..I..........:........::.....:::.:.....ll:ou~.................,.........,....,::.:....::............:~: .............
Place of Death ........................................................................... :... lIq!V
Lo~g
Ill? ..............._.....................................
Physician ........................................................................................... Address ................................................................... Occupation of Deceased............................................................... Social Security N c ............................................. . Name of Employer..........................................._............................................................................................................
Address.............................................................................................................................................................................. Charge to ........................................................................ _........ ~ ..... _Address ................. :.................................................. Order Given By............................................................................. .Address ................~ ............................................... ..
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Date of Birth ....................................................................... ..Age...................... (Years)
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Outside ca~~t:~e~ault*.~ · Embalming Body ............... .
......................... _._..............................................
County................ ___ .........................Township. __ ............. __ ___ .______ .________ . ___________.Phone l'il"o ..__________ ..__________ _...._______ ._____...
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Casket .........................................................
............
Gloves $....., ....·.......... Chairs $................... . Flower. $..................Palm. , ................. . C.~.ma.tio!1.................................................... N.wspaper Notices .................................. Telephone and· Tel.gr&ph .......:............... . Ambulance· ............. :...... :, ...... :.. ::.:............ :
.. .......... "Funeral ·Coach..::.':.,.;:_.. ~:. : .....~~ .:. ~ ......:: ...... .
...........~' .passengercars··::···:·····::······:···.. ·· ....····· .. ···1 Pall ,Bear.ers' Service ..................... ;.......... T~ansferring Body.................................. .. Opening of Grave ..................................... . Cemetery Charges ................................... .
Lot .............................................................. Misc. Transportation ............................. .. Shipping Charges· ...............:.................... Clergyman .............................................. . Singers $................Organist $................. . Cash Advanced ........................................ ..
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I -··········~·~·~~. ·A~~~~~:::::::::_: :::::::::::::::::::::::. ---,_
Remains to be shipped-see reverse fol' details.
Interment
at.............f1!
Lot No .......-..................................... Section No............... _............................ Grave No ............ ~....:: ............................ · R\ n l.:,r k , .... ·.... · ........· ....· .. ··········· .. ··-·.. ·.. ····
D Lodges D Pall Bearers
Information Given To: D Relatives 0 ' MusicHuls
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Attended To:
D Perm it D Bill Rendered
~nsuranee ....................................................................................... . FORM 52.35 SuPeRIOR FU N"'R AI. SUPPLY COR!" .. CLEVEL.AND. o:·tl o.
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(&one) CHEGr EA= ITEM AS COMPLETED
FUNERAL RECORD OF Yearly No ....A~
No...................._.. _.._.. _
..L.q..t._......_...
Casket ...................:.................................... $............ ..... . (Style) ( No. )
Name. ...... _.................................~ . .cO"~jf ............_................................................. Sex....... lI1i1:!:€!::...........
Outside Case or Vault ............................................ ......
Embalming Body ............ .
Address..................................................... _...................................................................................................................... . County ............____ ....._____............. __... Township..................... ____.__ ..___________. __.___ ..Phone N o....._________....__ .....____............... . Where B OI'D... ...................... _............... __................ _... ______ ..____..... __... __.....___... __..... ____ .Race ........ __ .......... ___ ................ __ .......
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. .............. ..
..._.) Professional Service ...... ....................... .. Hail" _Dresser............................ . Suit or Dress ............................................ .............. ..... . Shirt, Collar , Tie .................... ................. .............. ..... . Shoes $...................... Hose $...................... .................... Under clothes ....... :.................................................. ..... . Door Spray ................................................ ....................
.!;l(Years) ...... . ................. .............................. _....... (Months) (Days)
Date of Birth....................................................................... ..Age..........
How Long Resident in Community..............................................._..... ___ ......".__ ._ ..... _._...... _...__ .__. __..... __..________ .. ____ ...... Single........__..............Married........................Widowed.......................Divorced......................Child............................ .
Husband, Wife or Child of ............................................................... _........ _............................ _.................,_ ...............
Gloves $........c.••••••••••Chairs $........................................ Flowers $..................P. lm. $.................. .................. ..
Addr ................_...............................................................................................................................................................
CrematJon ................................................................ ......
Clo.est Relatlv............................_.................................................Addre.s ..........................................;.......................
Newspaper Notice .......,......... ,.....,........... , ................... T.I.phone and T.I.gr.ph........................................... . Ambul.nce ....................:........................:.. .............. ......
Father'. Name...............................................................................Birtbplac .............................................................. Mother's M.iden N.me................................................................Birthpl. ce.... ........;................................. " ............ Cause of Deat h...............................................................................Contributory.........::.........................:.....................
Occupation of Deceased............................................................... Social SecUl'ity No ............................................. .
F uiieral Coach ......... ~~ ....... .......................... ':.::...:........... . Passeng er Car s~ ................ __ ................. :................... ..... . Pall Bearers' Service .........._.................... .............. ...... Tr ansferring Body.................................... .............. ..... . Opening of Gr ave.................... ................. .. _........... ...... Cemetery Charges .................................... .............. ......
Name of E mployer ..........................................._..........................................................................................................
Lot .............................................................. 1... ..... . . ..........
Address .................................................................. ........................................................................................................... .
Misc. Transportat ion ................................ ,.................... Shipping Charges ................ ......... ...... .. ........
Date of
. ..................... Odob (!,!!,..5,......./ 9'6/ . ., .................. '. Death .......................................Hour ....................................................
Place of Death ...............................................................................1Iow Long Ill? .............................................. _.._ Physician .......................................................................................... Address ..................................................................
Charg e to....................................................................·......................Address ...................................................................
. .... .....:: •... . .. ...... ... :. .. ... Cler gyman ........ .............................. . ..• 1.. .•::.:: Singer s $................Organist $............... . Ca sh Advanced....................................... .
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......................................................················1··············
Place of F uner al Service ................................... _._......_.._........................................................................................ _. Clergyman ............................................._......................................... Call for? ................................................... _........_
...... ..._..... ...,.................................................... .
Address ... _............................................................ _ .......... _.................._...................................................................._...._
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Total Amount .................................. - - - -
Rema ins t o be shipped-see l"everSe f or details.
Interment at................._.....................__ ............................................................................................................................ Lot No ..............................................Section No ............................................Grave No ............~ .................................. Rt m;.} r k· ················································· ........................................................................................................................ .
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10 Death Certificate
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Perniit Bill Rendered
Insurance ......................................................................................... _ F O RM !5 23 !5 5 U P E fU OR FUN ER AL. 6UPPL 'l C OR P • • C L. EV£ L A N O , O H I O.
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CHECK EACil ITEM AS COMPLETED
Date........
FUNERAL RECORD OF Yearly No...._...•.i:f!I!l.I...9..s::. ........
N0 •.•....•.•.•.•....•..•.•.••..•••_ ••__
Name....... _........ .............(i.yJ.e..(). .ev..el.and.!:I.e{J.e.rf .................................................Sex.. ../!JSgffL.........:
~x.et fl1.i.Mowti.. Address ................................._............t. ........~............................................................................................................. . County...
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No.............................................
&vu.if...0! r. ........ un.:t~.......... frlLMo u.Iu..ie...................... Where Born. ................... ,...... ??!!d". ............_...........................Race........................ Date of Birth...rf!k~J.. ?~.....!.&/Q........................Age...................75....................................................... (Years)
(Months)
(Days)
Casket
(Style) (No.) Outside Case or Vault....... Embalming Body ..-.............................. .. .........._. Professional Service .............................. . Hair Dresser............................................. . Suit or Dress ........... _................... __ .......... . Shirt, Collar, Tie ...................................... I' Shoes $...................... Hose $......................
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Dnderc.lotheS .............................................. 1 Door Spray ._ ......_.................... :.... _............ . Gloves $....·.......... _.....Chairs $........... _....... _ Flowers $..................Palms $...........,,, .. _.. Crem~tio_n .....-... ,.,.~............-.............. ~. - ......... .
Husband, Wife or Child of..................... ./jaa.a;..l3aD.b.. lI.e./.J.E.:;. ................................................................. ,.... Address ............._.....................................................G~~ ... ~~.~ .,..............................:,.............
.....:.... Closest Relative....~.t;!.!:..Ij.'?1!:.~ ...............c: .......::::.: ...........Address ..::.:....... l.~:j!J!:i2Q.tJ!l:!::......... Lee lien eu. ... . ... B' 'h'l . .. . ....:. Father,B Name.................... ~.. ~ ...................................... _.._...:. lr.t P- ace ............................................................_. M h ' M' d " N .. . /'rlUJi..e Unhnoun. B' hI ' . . . ot er s 5 1 en~·~ .... ·...... ·:· .... ·.... ·.... ·.... ·A··:··:~:·: ......··..· Irt ~ ace· :::t="·:·:·:"o"-q·:·o:"::·:·:·::":·· :;," Cause of Ileath...................... ....... .................
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.
N arne of Employer ........................................... _......................_._ .... _.... __ ....... _......... _..................................................... .
I.I1i..do w............................... aru:L c!U.ldA.m .................... _.Address ........_......................._............................ . __ ....
Charge to .............................
Order Given B~·........ ~~~';e.. g<~, .. ~n&~~,~, .......................Acldres',....................~ ..c,..........................................
..
Misc. Transportation ................... _............ ............... 1 Shipping Charges .................................._. .. . .. ..... . .. 1 Clergyman ........................-..................... .. Singers $................ Organist $................. .
Date of Fulneral ...... v.!~eQ:~,.~~~ ~y.g[.;, ....... ~;........... c......TiIne ... ........ ,;;~~! ..1~,(~ . .......... ........................... .. Place of F mner.al Ser:"ice'................llj!,"')(:
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Occupation of Deceased..._._._.../Q!!l!J..M.._____ ................... _.......... Social Security Nc ............ _.................................
Address ........_.................................... _...............................................__ ..... _........_.. _................... _............... _.........................
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S,;!~~!';~ ::::::::::::::::::·::::::: :::::::: :
4 ·''''''''1......................................................................... Total Amount.........................._....... -
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Remains to be shipped-see reverse for details.
Interment at.............. j)ja.pleuv.o.d. . r;en..eieJUFC~· .. /rJJ..440w!..L ......................................................... Lot N 0 .. ........... . __ ... __. _... .. .................. Section N 0 •.. . . . ... ..... . _. _.... .. . ...... ... . . . _...... Grave No ............................................. ..
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Permit Bill R.ndered
Oci:nbe/t 8. /96/ Date............................ No...._. ..._..__............._._
CHECK EACTI ITEII1 AS CQMPLETED C.sket:v.~. §..::l.0r/.-?~............ (Style) (No.) Outside Case or Vault..............................
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FUNERAL RECORD OF
WLLI.ian
r
Y.arly No .. _...
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Date of Birth_. f.I1M.m...~.mJm.mrRIb.. _u. .Agemuum..m.(Years 8.9m........... uu.(Months) m. ..m..mu. . ummu_ . .. m ) (Days)
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Hose
Gloves Flowers
CO'aclr;:.:. ~:::
Tr~nsferring
Opening of Grave ..................................... . 'Cemetery Charges .................................... '
Lot ........... . ............... ... . . ..... . . .. . .. ......
~:::s:~.~=~~~~~'.:::::: ::::::~~!~~.~: :: : : :: : : : .: ::: : : : :: : :: : : : : : : : :: : : : : : : : : :: : ~~:::eG::~~~;.~J;:':/i)j,;;;::.:·: : .: : : .: : : :·: : : :~::~::::::::::::~~:: ~=".:: : : :
Misc. Transportation ............................... . Shipping Charges .................................... . Clergyman ............................................... . Singers $................ Organist $................. .
Date of FuneraLQw..Q~.J.L~. J96L. . . . .. ..................Time.................? .'[•.~k.......................................
CjdJ.:tr;;.d. . . .. .... . . ... . . .. .... . . ..
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Remains to be shipped- see reverse for details.
Interment at..................... )~@!!.. » ~1"e;.1Ljbe7.!g;t;.~'I14!L ....................................................:..............
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.:: : ;..-._ sD Pall LodgesBearers . ~,
Lot No ................................. " ..........Section No ............................................ Grave No .........................:.................... .
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Occupation of Deceased........d.,~/,,!!P.19..~...gz,.............Social Security No ..J9.5-=tJl:Q{JI/Z ...........
\
Chairs· P.lms
TelephOlle ·and .Teleg,..ph. . . ... .............. Ambulance ....... . .......... . ::. . . . :. . . ......:. .••.•....... 'Funeral" ..-::·::..................... .. .. .Passenger Cars,. .,. ..... ..:. ... . :.:........;.....:.: •......,;....• l?all ..Bearers' .Service........._............•..._....... """....,. Body... ................................
Physician................................................................ _.........................Address ...............................-........'...................... ,...~
(
:: :: ::::::: :::·
sass
SUPERIOR FU NERAL SUPPLY CORP .. CLE VO;: LA NO, OHlO.
o
o
Information Given To : D Relatives D MusiCians
o
Clergyman
D Singers
Attended To:
Death CertiI1cate Payment Ar ranged
Insurance ..................................... .
D Permit D Bill Rendered
Odobe//. 8, 1961 Date. .............. _................................... ..
CREe.. EA=
FUNERAL RECORD OF Yearly No .................Iil!1f. ..t.!2.1..
No................................_ _ Name. ................................ .c~~ Addxess ................................................
County..... J.v.~~
. .II!d:~./if?~..............................................
AS COMPLETED
.':::J!.(!!/.~s.e&'
Outside Case or Vault ..... __ .__.... __ ..............
.1!:U.a.v...i.W....I!1i.Mo.IY.I.i-...........................................................................
Embalming Body .................................. .
Sex.....
No ............................................ .
Where Born. ...........~1!!Jd" ............................................................................ Race ................II/AY;'!',...................
:::::::'::1~:~!es~~e::~r~e.~~i.c.e :::::::::::::::::::::::1 . . . . .,.... . .. 1
Suit . or Dress ....-... -....................... ----.. ----..
....
Date of Birth. .....O'e~.e&.. .I......L8fJ6........................Age..............7Lt.............................................................. (Years) (Months) (Days)
............ Shirt, 00ll\tl!; Tie ........4.·~5 L .50. .. Shoes $...................... Hose $.................... ..
-How Long Resident in Community..........._. __ .............___ . ___ ..... ____.................. _.............. _... __ .......................................... ',1 fTl£1/1./U.ed W'd .. ................. lowe d....................... D'Ivor ced...................... Ch'ld 1 .......................... .. S1'ngle........................MarrIe~....
Door Spray ----.. --........................................
n.
A.L
1/ ~ .. ......................................................................".
Husband, W'ife or Child of.....................(&.V.!i'... lJ.{¥.LI.I.e. ..
- .
.
.
.
Address .................................................................... f..ru.a.v."'eJU.... .. t.v.!Q/.I/.iJ......................:......................:........... {k 1/ ~ I " ~ A
I
(No.)
fTl5Jd..f? .............
......................'l'ownshiP..................................................Phon.
(
Casket
ITEM
Underclothes ........ --......... ----... --....---.. --.---Gloves $.................... Chairs $................... . P I ~ owers ~.... .............. • ms ~................. . Cremation ................................................. . News.p aper Notices ................................. . .. ... ':..... Telephone and Tel.graph ........................ .::.:.....:. Ambulance .:.........................................:... . ........ .... Funeral' Coach .... :.'........ .__.. _......................... ..
Fl.
Closeat R.lat lve.......... ...'
...
............................ _..... 6.......................:.............:.......
I!•..J9.6./.. .......... - :.......... ., ...:...,- _. . - . .. , - . _. , . ,- . ." :~::c~:n~~~t.Q;;,::·.. ·{i'~:~fl~·.· :~ ~::~::~.:I,II.!.::r~:p.;~::)iC~;,;~:::::::::: !Ja
. ·. . ··. ... . . ·.·.... .,. . . . . ,. .
Occupation of Doceased. ........~e&......................................Social Secu"ity No ........ Lt9~:~9.!.6.l........ Name of Employer ..........................................._........................................................................................................... . . A"ddress ................................................................................................................................................................... _.........
Charge to ....... 1Ja.v e ..Keeli..n.g. .............................. :.................Address ................................................................... Order Given By......... ~.t::l..d.if~T
. .. . . . . . . .
.Address.2 ..
7i)i:..................................................
Date of F uneral. ......................................,l ..... . .9.L..........................Tlme ........................................................................
Place of Funeral Service ... _..........1::G.La.v.i.eJ.tJ. ..f.apt.i./.d:... (Iw.a.ch. ................................................................. Clergyman ........................................................................................ Call for '! ..........................................................._
(
)
D
C:"'S·....··... ·.. ::.. ··· .. ···:.... ··:.... :·:.. :· ............ -~a;lseBnger a - earers- ervlce .....,..·•. ..................... .T ransferring Body .............. ................ J Opening of Grave........................ _......:~
=:
Cemetery Charges ........................... .... Lot ............................................................. . Misc. Transportation ............................... . Shipping Charges ................................... . Clergyman ............................................... . Singers $................Organist $................. . ~d2~"~ed
. ....................... . . . . . . .
:f.ij~;;::::::::: :::::::::::::::::::::::::::::::: : Total Amount.................................. I -
·- ·· -
I-
Rema ins to be shlpped-see reverse for details.
Interment "t .......L!I~.... I~d...!W-,jatU; ..l/!r.lLetea;,!........................... ............................ Bearers
R
............................./fo..!.Z ...J.W!l4l.!!.1i?,g9
Information Given To : D Relatives D Musicians
Death Certificate Payment Arranged
Attended To :
o
Clergyman
D Singers
o
Permit
D Bill Rendered
Insurance ..... .... ,...............................................................................
257
Octobe/t / j z..._/96/ Data............ __ ...... _........... .._.. _...
CHECK EACli ITEM AS COMPLETED
FUNERAL RECORD OF Yearly N o"" •• _••••••_•••i(J!L._ ......_...
N0 ••....•..•••.•.•.......• _.""•••._ . _
Casket & .A eJl.l/1 .C2A ............................
Name. ...................................... .clw!!J,f0.j)~]!J.dJ.M ................................................. Sex.J'J!?,j,g................ Address ................................. _.................{p.4.11yj,!,J.,g,.../!1:i4.9.QuM,..................... _...............................................
Bcvvt County......................!/:...................Township ......._.........................................Phone
(
N0 •............••...••...••... _...... .••......
Outside
Ca~~t~~e~ault ......... ~~".:)........... .
Embalming Body ....................................
---,,----,--1P r ofessional
Service ... --~ ..... -. -........----.. --___....... . Ha·lr Dr esser. __ ... __________ .... __ .. : _____ ..... ___ _______ .
I
:~:fB::~:::QJJ.':..t:~7.;;~:: : : : : : :::~~~::::: : : :: :(Years) : : .: :::~~.c~::: :(Months) : : : 1J!};.~:(Days) : ;;;,;)::24 rru..I2J...,);.•. ~1 Shoes ~~:~~rc~~:;~ ;;~::~~: ~: : : : : : : : . . . . . . . . .. Hose Cl! ...
H
... .
L
R
'd
t · C
$......._............. $...................... .................... Underclothes .......-----..---.. ---------.... ---.... --.-- ........__ .... ... _.-
't
si::le.::~ :~~ ~:.~:rri::=.~_~~..~~~~~~:::::;~~:~:~-_:-.-.-.-_-_-_-.-_._-.-_._-_._._.~~~~~~~~~:~~-~.~__.-___-.-____..~ ....~.~.:~..~._._:~~~.~~~::::~~~~~~~~~~~
Door Spray -...... -.... -..... -............................................... -.
Husband, Wife or Child of...................... _................................ -...... --.........................-............- .................. - ....... -.......
Gloves $ .................... Chairs $........................................ F lowers $..................Palms $.................. ................... .
Address ..........................._...._......................................................................................................~........ ..... .... .......... .........
Cremation ..................................................................... .
~~:::'sR::::~::c.~~::Q:::]~~~::::::::: : :::::::::::~::::~:~::c~:::::::::::::::::::::::::::::::::::::~::::~.::.:::::. : : : : Mother 'S
~::;~:::ra:t~:~:;;~~h:::: :::::: : :::::::::::: ::::::::::::: : : :
Ma·den Name.J.-'--........................................................ ~JJ.a inaxi.n.e 7?ob€ld:4on.. .Bl·rthplace..._......................................................_. 1
Ambulance .........................~ .................... ~ ......~............~ Funeral C oa-eh.~:... ~~·:::.'......... ::~ ...::.~~ ............ :: . ~.......... ..~ ~ .. Passenger Oars ..~~ ..~.;... ;..,::.·.......... :;:.;.::... ,.: ..;.. .-~....... ......
Cause of Death ...............................................................................Contributory .. :......:................:.:~ ............::.:........:..
L ~ LOLL IG '/:/;, n; +~ t . ... .i.n,~f:lJ.t...4 .. ...e(,1~.••.......•.... lIow
_.t .• l
Zo.· :YI J!
'M'
.. ,
,.
Date of Death.....Q=uQ.e!.l...• •",~ ..•. ··AI• .......•...........•.••.•........•Hour .............. .~ .;t.I... .. IIJ........................... _.......
J
.. . _. .. . Place of Deat~ .. ., Long I~? ·······jj1·..····iiJi:.J··········....·•···· Physician ............~.......~......~........................................ Addres •.......l"g1.~!(;.: ......E!t.•.......:...1!?Y!.!f:........ Occupation of Decea sed...........i.a{t:mi................................. _Social Security No .............................................. Name of Employer ........................................... _............................................................................................................
P"11 Bearers ' S01'l'lce · ................•.•..•......, ... ....................
............Tr"n.forring Body•.•_................................................... Opening of Grav. ...................................... .................... Cemetery Charges .................................... I.................... Lot .................................................................................. Misc. Transportation ................................................. __ Shipping Charges ....................................................... .
Addr ess ........................................... _.................................................................................................................................
(jyv.J1
7. dJ..
~D:a:te r:oefG:F~u~~n·e·Br·~a : : : : : QliijZ~i.f:: : :·: : : :· ·-: ~~~~:~:::.: . : .: :.: .:.:J:.:.ii::.: : .~.:. .:.: :.: .:
~:::!~::~. .: : : :..::..:~.;;~~;~~. $: : :: : : .: : :..:::::::::::::: :::::: . ....... ........................
..:.::..:.:.-: ..::.:.:.:.::.::.
Place of
c.')ci1~:vr ~d
r. .. - .'_.1.1. ..-b"'.,""' f ~"'./.eJlJJ • ce ........I:Y-r.I,MI&~ .• ."..................................................................................... _.. -. Funeral Se•~l·
.. ..... ................ ......... .......... .. ............... .
~~::::~::::::~:~Z:~~~~~;.;:L::::::::::::::::::::::::::~~~~.~~~~::::::::::::::=:::=:::: : : : : : : : : : ;: : : .~: : : :.-= (
D
Remains to he shipped-see rever se f or details.
Interment at....... _.......(j.&i.nth...-Cf!11l.ei.eIJ./f.................................................................................................. -.. -. L ot N o.................... ".............,........ ,,".Sect ion No...... __ .____ .. _.. ________ ... __ .. __ ......... Grave No .............................................. .
R ,-m ' r k •.................... ] '...
t?!4g
[email protected] ..!!I:!d..'!,....i.,rJ!.,~(!,..!!!-:Yh. J?:4&A.q;I;.,0....IY!J................
o
Lodges
D P all Bear ers
o
Int'br ma tion "&'ivim To: D Relatives D Musicians
Attended To: Death Cer t ificate Payment Arran ged
o o o o
Cl.rgyman Singers
Permit
................ . ....................... :0...q7fJ.•..................... .. .... ................... ...... ....... ........... ......... ..............................
o
......... . ........ . ..... .....§.f!l'I,:Wtd.Lod5.e;!&rry:i(]!I.J! ....... ... ..... ...... . ...... ....... . .......
Insurance .. ____ .. __ ____ ............. __ .__ ............. ____ ............______......... ___..........
FORM 5 ;;: 35 8UF Il: R1 0R F UN EHA L SUP PLY C OR P .. CLEV ELA ND. OHIO.
Bill Rendered
Date-___.. _...Oc:.hJbe/l.. __ .___......... _.....I], _......_/96/ ......__.
CHEe;;: EA= ITEIIl AS COMPLETED
FUNERAL RECORD OF Yearly N 0 ••.. _ .•••.• _ •. 101...._...... _...
N 0 •••.•••• _••• _ .•. _•. _•.• _ •..••• _ _ N ame....... _._....... ___ ._ .... _..
.J.a!!'!!:!:..2.Of1:(!...B..'!.:~._._.............._. _ ....._.._. _.._ .._._ .._ _.._ ._ .._Sex____ .!:.~~.........
2037 tVolIih. /I1ai.n. _...........S·.f: fA ... --......... /Il.w/.JOwU.. Address..................__ ..._......... _.......... _......._.............. ~~~ --...--_ ....................... _. __._____ ._..... . A
County.....[ja.e.en..e. ... ____ .... ___________ Township __________________ .__ ...................... __.__ Phone No ... __________ .__ ..... __.. ____ ...............
..
Where Born........ __ .j.~dY2. S.f2M.(J!J/!~--.~.I!&f".._. __ .___ ._._____________ ._._Race _____.__
(
.1.ma.e......._. .............._
Casket
(Style)
Suit or Dress .. _...S:fP..!,f1......... _______________ _ Shirt, Collar, Tie ..............._.... _................ .
Shoes $_____ .. _...... _. _____ Hose $__ . _________ ._____ .. .. Underclothes ................... _............._......... . Door Spray .. _...... _.....:._ ............................. .
:i::l~~:~.~:~~~~:~:~:::~~;~~~:~.-_·~~~::;;~:~~~·~.-: : : :.-.-::-:::::.-..~~-;;~:: : : : ::: : ::: : : : : : :
Gloves $........._____ ...... Chairs $.............. __ .. .. Flowers $... _._ ........... Palms $................ ..
Husband, Wife or Child oL ..................... ]IJ!?!I... !Jl!:.~ ._ Address....... _...._.................................... _......................................................... _..................._........................................... Closest R.lativ........................................................... ;...................Addr••s._ ..... _........................................................ .. Father's Nam.......,I'=ea.. Sh.i.pnqn................................_.....Birtbplace.....................................:........................
....................................-.--.................-...............
Cremation ............ _.....................................
Newspaper Notic.................................... Telephone and T.legraph ...................... ..
.
fl6..t. ....... _.........................
--·_--V ......
:~~~c~:n~~p.~_I~_:ziI_J¥ltJ~.-: :.:.-: : : : : : : : : :.-: .-_.-.:~:;r~:~~_~l~~)ii~~:: : : : : : ::~::: Occupation of Deceased.__ .___ . __.Iw.lJ1.~{g..
..____ ....______.___._____.Socia1 Security No_:_.. ________ .......................... _......
Name of Employer ........................................... __...._.. _.. _.. __ ......... __ .......... _.. _._ ..._... _.............._...._._ ......... _.............. _....... _..
Ambulanc................................................. Funeral Coach .................... __ .................. .-... ............. Passenger Car8 ....:................................· ~ ... . Pall··Bearers' Service ......... :..........~.~ ... :.... . .T ransferring Body.................... _.... _......... . .Opening o.f Grave ........ _...... _,_ .. _._ .._._...... __ .. Cemetery Charges ..................................._ Lot ... __________ . ______ .. ______ .. _______ . ____ __ ... ____ ........... Misc. Transportation_ ...................._......... . Shipping Charges .................................. .. Clergyman ....................................._........ . Singers $....._.......... Organist $_............... .
Address .... _....._..........._....._.. __.... _....... _.. _......... _........ _......................._...... _....... _....._... _........ _........ ___ ..... _.............. _.... __ ........ _
Charge to .....l!!l2#.. Bt~dian.an.· &"-7;;;.;.:-T-· .. ---Address-.. -.-.sp&i.r.lfJp...W4--.~.IJI.!d" Order Gl von By_. ____ .. ____._.. __!l-. ____________..._______.__ .___ .. _t""':'::'-~ ... _..,Addr•• s________ ... _.__ ..___ ._ ........ _._ .... __ ._._.__ ... _......... _...... Date of FuneraL Ddob,=..J'Ir.JCj6L .........................___.Time ________ 2 __ 'P. /rl •._____ .... _ ...... __ ......... ___................ Place of Funeral Service_._. __ .... i.I.?Il-.-CA.Whm._...... _ .._................___..........__ ... _...... __.___.. __.___ .. __ ._. ____________._______.___ ._. Clerg-yman_'B.ev._. .IOJJmJ.j-.Beckel1..._._ .___......._.. __ ..... _... _... ___ ._ .. Call for? ..... _... _________ .__ .____ .__ ._____ ... ____ ._ .._... __ ....__
...
(
D
I
(No.)
Outside Case or Vault............. _..... _.. _._._ .. . Embalming Body .... _.... _·.·1Professional Service ................. ---.. -....... Hair Dresser................................... _.......__ .
nate of Birth. ..Q.W.Qf:tL4l.....J9.6../...._.___ ......_. __ .__ ._ ....Age... _....._.._~?_ .. _. __ ._____.. ____._.................. _.._........____ .-.. (Years) (Months) (Days)
Mother's Maiden ~am1:;:;;;;;:~!~~~+.y.:L ................ .BirthPlace....... ~:;;:r-~ Caus. of Death.. 6idL.~........4?................ _............ _..Contributory...~ ................ Date of Death_.P~.~.f!J3:.J3J... Hour._._........................................................... _.......
&{.an...&r.a_Mlt.-Lced....... _:
()aS~~~r.~:::::::::::::::::::::::::::::::::::::::: <
··········;~·~i···A~~~~·~::::::::::::::::::::::~::::::? .:-,--,_ Remains to be shipped-see reverse for details.
Interment at ___ ._.__ .S~-.cp!-e:t.'?!!-_!f_---
.. ----..-.........--..-..........................-.......-..--------.----..-..-..--...-__ ._..... ___._____.__
Lot No ................................... _...........Section No ............... __ ..................._.. _.... Grave No._.. _...................... _._ ................ . R<'m a rk , ... __ .___ _.. __ ___ .
..c;~:l. ~ed§4:~.P'5/7:_te,t:!:i!!rI:_ ..~e,_ .. ______-----...-.---.--.---........ -.--- .. --.- ...
: : : : : : :_ : : : :::::::::::: j~~::6i.d.:lfk'7'2.::~~=~::~·:: :::::::::::::: : : : : : : : : : : F OR M 523 5 SUPER I OR FUNi£ RA l. SUPP l.V C ORP •• Cl.t>VllLANO, OHIO .
o Lodges D Pall Bearers
o
o
Information Given To: D Relatives D Musicians Attended To:
Death Certificate Payment Arranged
o
Clergyman
D Singers
o
Permit
D Bill Rendered
Insurance.... _._ ...................... _.........................................._.............. .
259 Date. ......
.Qr.:!P..Q.
CHECK KA= ITEM AS COMPLETED
FUNERAL RECORD OF
&iX.
Casket ....(,.... .a.f?&'!.i£:.M............ (Style) (No.)
Yearly N0 .... _ .••••• _.1./0..... _...... _...
N 0 ........ _ .•.•....•..•.•.••.•••• _ . _ N ame....... _.......................f)dOLllJ..&;!;d!.a...I!b.Q.dIu~f.I.
.............................................Sex.... f.gmrd.R-..........
Outside Case or VauIL. ____________ ._____.. ______ _
IJ!adzb_..W!J.k ............ /'I'JU,~w.Y.:• ................................. _............................................... Address ................................._..................
&wj........................TownshiP....... _........ _..._...........................Phone
County......
(
Embalming Body ........... __ .............. _....___ _ Professional Service __ .... __.... ___ ............. _.. .
No ............................ _...............
Bea:W.. NehllLlAk.fL ............_..................................Race................... uJLi.Zg ......................... Where Born............. _........_.. %_ ..................... Date of Birth....... f)f?,~_'?!1:.JQ,.....I.Qzz ...................Age............/}J....................... _.. J9.................... /i ....
If[:o~t~y;.,~~~~;::~: : : : : : : : : : : I
How Long Resident in Community. __ ... ____ .................. ____ ... __ ...____...................... _..... _....____ .____ .______ .____ .________ .. _______ ......... · 1 M ' Ii W·d d ud.dowed D· d Ch·ld mg e........................ arne ....................... lowe ....................... lvorce ...................... 1 ....•....•............•••.•.
Underclothes ............................ ----........... . Door Spray -----.. --.------.----------.----..-............ .
~:::::s~:..~~~._~~.~~~~..~~:::::::::::::::::~:::::::::..~~~..:::.~~.~....:::::~::::::::::::::::::::::::::::~::::::::::::::::::~:::::::::::::::
~~oewmeartsl· on$··················Palms $................. .••.••............•..................... •...........
Closest Rel.tive.........Lama.en.Ce..fl..1aIWR-bI-........................... .Address ....................................:... :;...._.. ,.............. Father's Mother's
Newspaper Notices ...............:: ................. Telephone and Telegr.ph....................... . Ambulance ....:...........................................
(Years)
(Months)
(Days)
s: uJ!f:. diu;!!-
S
Gloves $.................... Chairs $...........,....... .
OfI~::~~~~~~~!3~~~~~~:::~::::::~(::~~~~:~.~~~~~J~~~%:~t~:::~:::~::;~;.~:::
Cause Date of
Funeral Coach Car........................................... .......................................... . Passenger ..... ,...... 1Pall Bearers' Service ............................... .
Place of
............................ Social Security No ..............................................
Transferring Body................................... . Opening of Grave..................................... . Cemetery Charges ........................... ........ .
Name of Employer........................................... _............................................................................................................
............ 1Lot ..............................................................
••• •••••••• .• 1
)
Occupation of Deceased........ ./:w..Y4.~t~
Address ............................................................................................................................................................................. .
~~:::eG::·~~. ~:~~~~~~q;;:i;::: : : : : : : : : : : : : .~~::::::::::::::::::::::::: : : : : : : : : : : ::~: : : : : :: : : : : ./8.....
Date of FuneraL ...QW.9..
Misc. Transportation ................................ Shipping Charges .................................... ............ .. 1 Clergyman ............................................... . Singers $................ Organist $................. .
. ............ 1
............. 1
C.~~a.!:;:r.~:::::::::::::::::::::::::::::::::::::::
..C@&m...................................... ........._.._.
Clergyman.....iAank..!:1a1L·"'{pb1n..i1end.e.a.LxJJ:1. .........Call for?
(
D
::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::: 1 Total Amount.................................. j - - - - ,-
Remains t o be shipped-sea reverse for details.
Interment at....................H~v.ul~U1 ... l~~~~ ·jC£~e~~~ ................................ "~== Lot No .......................................... _... Section No ............... _............................ Grave No .............................................. .
R, m" .. k' ......................]JQ..Jwn.i.go.n.. DJ.ue ..blen.ded . d1v.eIL.pea.!.eci..li:t11....duJJ.n."'................
..........
....................... 2llQlLiJ-.(jnpaeM _C.fl.ep~ld.lLe .. l/.eb.ei={Jai. ..dz.i.M.ed.;xmeL ..o./
.. .................. ... ...........It.el.l/.ei=....5.painf}/.i.eLd. (pd.e:t.~.-Co... FORM 52.35 SUPERIOR FU NERAL SUPPLY CO R P., CLEVELAND. OHIO.
........ . ........ ...... ........
o
Pall Bearers
Information Given To: o Relatives D Musicians
D Clergyman D Singers
Attended To: D Death Certificate D Payment Arranged
D Permit
D Bill Rendered
Insurance ..........................................................................................
CIIEcrr EA= ITEM AS COMPLETED
FUNERAL RECORD OF
.".v...:u.L&.4eJtV~.............
Casket ...
Yearly Nooo ......... LL.L ....................
No................................_._
(style)
::::~~:: .~: : : : : : : : : : : : : :.~~:1;:;~~1rli1.;;;,;;;;:: : : .: . . . . . . . . .::::~::. . . .: :. ~~~::::::::~=::: :
Embalming Body .................................... 1 Professional Service ............................... .
county.. __~. ____ .___ .._. _______ .____TownshiP_ ......._______ .. _________. ___ ................__ .Phone No.___________ ._______ ..... __ ._ ............. ..
Hair Dresser... &... ClJ.j~ .............. .
Where Born.........~.. &.':!!.~ ...~.~ .... -.................................. Race ..........
(
I!!ilie"........................ Date of Birth...'JYd¥...?J......L&z ..................................Age ........Zlt.................................................................. .. (Years) (Months) (Days)
~~!!t~rc~~::~ ~~~:::::::::::::::::::
Underclothes ............................................ Door Spray ............................................... .
Single........................Married........................ Widowed.~~... Divorced...................... Child .......................... ..
~~::::.~:. :~~. ::. ~~~. ~~::~::: : : : : : : : :::~::?~~~~~:: : : : : : : : : : : : : : : : : :~: : : : : : : : : ~: : : : : : : : ClosOflt Relatlve.........
~ . . ... i •••• • •
oo ........ ....... . .. .............. .........
. · ;·. . . ·. . . . . . . . . . ..
...•.. -.-...
J. ........
~
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Address ______ ........... _..... ___ .__ .............. __ ......... ___ .. _____ ............ ____........ __............____ ..................... _.......................................... .
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Shipping Charges ................................... . Clergyman ............................................... . Singers $................Organist $................. .
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Lot No .... _....................................... Section No ............... _............................ Grave No .............................................. .
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CHECK EA= ITEM AS COMPLETED
FUNERAL RECORD OF Yearly N0 .......... ...../.12 ..................
N 0 ........ .... ............ ... ........._
Name........................................L!l!.!!YJ..Hf'!J!1.!j....................................................................... Sex...
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8s!Mif.........................Township..................................................Pbone
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No .............................................
Where Born. ........1!.~~
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...........................................Addr•••.......................•....•...•.......•................•....•...
Fath.r's Nam• ..•.••.••tU.{.a.f>.a'. .GUi,a.....................................Birthplac ...................................... :. .......................
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....I..9.6..I.............................Rour ........................................................................
Place of Deat h,11.4 .......~~'.l:...l~
......................................lIow Long Ill ?.....................................................
Physician.___ ............................ ____ ............____ ...................................... Address ....__ .__ ._._ ..__ ... ____.. ________________ ~ _.... __ .. _____ . ______ .. Occupation of Deceased ________b!:?_Y4._~/l?: Social Security No .. _________________ ___________________________ Name of Enlployer ____________________________________________ . __________________________. ____. ______._. ___._. ______________________ __________________________________ .__
_____________________________.
P.. ddress _________________________________ ________________________________ . _______ ..... _._........ _... ____ .... _..._....... _..._._ ......_............... _..... _._.. _........... __ .__ .__
Charge to ....
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Or der Given By. _______ ..~!J.------ ...... --..... -.-...... --.. ----.--....___ ._...Address._. __ . ________ .............................................____ .
Date of Flmeral... ...... ;;.2~ ....I..9.6.L........................Time ..............2...?AJJi........................... Place of Funeral Service......... (,t..U.J!.f:!!..'1J...(jIIJp.ei............................................................... Clergyman ........ .7J.(!y.,...lf!!lQif...s..~Y..<;!!J:............................Call fo r ? ................. .
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(No.)
Outside Case or Vault __ _________ ._. _. __ ._.. __ ... _._ I Embalming Body _______ .____ ...._._ ...._____.... __ .. I · ___ _· ... .__1 Professional
Service ..... --............. ----.---.---. I-lair Dr esser.. ____ .. _____ ._____.. _._._. _____ ........... _.. Suit or Dress . ___ ._.... _______ ._____________ .___________ _ Shirt, Collar, Tie._______. ___.. ____ ...____ ._._____ .. __ _
Shoes $...................... Hose $..................... . Underclothes __ . ____ .____________________ .... ___________ _ Door Spray .....___.__ ....__ ..................... _.__ .... __ Gloves $.................... Chairs $.................... 1
F lowers $..................Palms $................. . Cremation ................................................ ..
Newspaper Notices ................................. . Telephone and Telegraph........................ Ambulance ................................................ Fun'eral Co.ch ............................................ Passenger Cars .. __;__ ...._.......... _.. _.....~ ......... . Pall Bearers' Service ..:_____ ... ____ ._ .. _........... . Transferring Body ___ .___ ________ ..._.....________ .... I Opening of Grave.................. _.. _... _....__ .____ . Cemetery Char ges __ .__.___.. _____ ... _...... _____.... . Lot .............................................................. Misc. Tr ansportation ___ ._. ______ . _____ ........ ____ ..! Shipping Char ges _._______ ..... _....... ______ .... ___ _ Clergyman ..____ .__ ._________ ...... ____ ........ __ . ________ --'S ingers $ _________ .____ ._Organist $........ _.____ ._ .. Cash Advanced._____ ._________.___ ._____ .._.....__ ._._._
J.aL.l?d.1.f!X............................................. Tot.! Amount.................................. I
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(Boone) Yearly N0._ .. _116 ...... _ .............. _. _.... _ •••
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Date of Birth...................................................................... ___ Age ...... _............ _.... ___ ..... _...................._.. _...... __ ...... _......_.. (Years) (Months) (Days) How Long Resident in Community.............................................. _..................... _...... _.....____ ..................................... .
Single........................ Married. .................... _.. Widowed ....................... Divorced_ ................ _.... Child .... _.......... _.. _......... Husband, Wife or Child of............................................................... _......................................__ .......... ,...... _........... ,.. . Address ............. _............_..............................................................................,............. _;.............c.... ;;...:.;.....................:.. . Closest Relative............................................................................. .Address........:.-:.;..::.:...... ;.;;.;.........., ..'.~..;....: ........:.. _ Father's Name...................................................... :.......................Birthpl.ce......................................-...................;.;.. Mother's M.iden Name .................................................................Birthplace........................;;:...................................
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Gloves $__ ..... _............ Chairs $_.... __ ........ __________ .. _.......... .. Flowers $.................. Palms $............... ___ .............. ...... Crematl.on , ......_............................................................. .. Newsp.per..Notic..........'.,............... ,.. ,...... .............. ....., Telephone and Telegr.ph ...................................... ,,'_.,. Ambulance :::...............:......................... :.. : ._:..., ............ . Funeral Co"ch::: ............~- _____ .. ________ .. _____ :: __ :: __ .._.. _........:...
Occupation of Deceased................................ _____ ... ______................ Social Security No .. __ .____ .... ______ .. ____ .. __ .... _______ ..... .
/, ...;....... Passenger Cars .. ::.. :................................................. ...... Pall Bearers' Service ............................... .................. .. Transferring Body............... ....................................... . Opening of Grave ..........................•_........... .............. ..... . ........ _... / Cemetery Charges ....................................
N arne of Employer. ___... _. ______ ___... ______ ... _____ ..__ .. ____ _____................... _.,...... "......___ . ___ .____ .. ______.__ .___ ._.______ .... _...._......................
Lot .. __ .. __ .. _.. _________ .... _____ .. _....... _.. ___ .. ___________ .. ___ .... ____ ... .... ..
Place of Death .. .?.J./:g j)g,..lig4~................................ R ow Long Ill ? _.... _.. ___ ...... __ .. _.... __ .... ___ ...... __ .........
Physician __ ..........................__ ....__ .............. __ ...................................... Address ...... ____ .... __ ............. __ ................................_..
Address ........................................... _.................................................................................... _.......................................... . Charge to ......................................................................... _............. _Address .................................................................. . Order Given By............................................................................. .Address .................................................................. Date of Funeral. ...................... _.....................................................Time ........................................................................
Place of Funeral Service ... _....................... ....._........... _........................................................................................ _.. _. Clergyman ........................................................................................ Ca11 for? ............................................................._ Address................................................................._ ................................................................................................ _.. _.. _.
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CREe;;: EA= ITEM AS COMPLETED
FUNERAL RECORD OF
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Misc. Transportation ............................................ . Shipping Charges .................................................. ..... . Clergyman ............................................................. . Singers $................ Organist $............................... Cash Advanced ....................................................... .
--.. -......... ----. -..-.----.- . .- -.......... -.--....-.. i.---..........
=::::::::::\ :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
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Total Amount.................................. - --
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Insp.rance ......................................................................................... . FOR .... 5235 SUPERI O R FUNER A L. SUPPL.Y C O RP •• C L. EVELAND, OH I O.
Date. ........Qqfp§.~.fJI_ ..!.~riL
CHECK EA= ITEM AS COMPLETED
FUNERAL RECORD OF
Casket ..( • .j3!lI~::S.f:-!!!"!".f;g1 ............. (No.) (Style) Outside Case or Vault............................. . E mbalming Body ................................... . Prof essional Service ..... ...................,.......
Yearly No .. ______L.L}_________.
No•..........._.........._......_ .__
.... ___.. __.. ____ .. ____.. _____..Sex...~_mg)f?__.
N ame.______ .. ___ .. ____ b!)?!j..:kbr!4?i'!_.w..~f?M
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(Days)
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Mother's Maiden Nam. __ ~-S::/;&l!..~!J:-- ... --.. B irthplace... -.. - - --- - - .. -.... ----- .. - - _______.. , Cause of D.ath_..... __ .__... _.. __... _. __._ ...... __ ...... _.. __. ____ ......Contributor y....__ .... _....... _..._:... :___... __ .... _..... . Date of Death __......Q0£~.'?!!:_.!.7.t
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FUNERAL RECORD OF
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Yearly No •... _...... _..
No•................... _.. _.. _...__
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(Months)
(Days)
Professional Service ................................ .. .......... , Hair Dresser.............................................. I ............ / Suit or Dress ........................................... . Shirt, Collar, Tie .................................... .. Shoes $___ ....... _____ .. ___ ._Hose $____._. __ . __ ......... .
. . . . ._. . . . . . _ . . .~~~;~::::~:::::::~~:
Underclothes ........................................... . Door Spray .............................................. .. Gloves $_ ...•.... _.......... Chairs $...... __ .... ___ ... _. Flowers $..................Palms , ................. . Cremation ................................................. .
~::l~~:~.~::~~::~:r~::=.~.~:~~:~~~~:::::;~~~~:~·"·.: -.-.-.:-.-.-.-.:._: ~ ~~~~.~~:~~.~~.-
'&,dw.!.!d.i!k(,/f!7.,f;Bm. ................................... _.................. _...............
Husband, Wif. or Child of.....................
Addx.ss •••••.•••••••_..........................................••...••..!ib.-.f:-edg,r.l,... i.1U,a&!lWR......................................;........................
Closest R.lative..............................................................................Address ................................................................ ..
Father'. Name.......&!?'!:~.!!J.!!~.1~ :BirthPlace.............................:.......:........................ Mother'. Maide~ame........ t!!:1I:!!!:1.~. .......... ["~..............BirthPlace ... _.........................................................: ~J 0 clff'" ,, -' . .-.- ..... -' Cause of Death~A .......~ ..::.l.j .............................~ontrlbutory ..........................................................
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Newspaper Notices ..................... _........... Telephone and T.le/ll'.ph ....................... .
................_.....
Ambulance ...... __ ........__ ...............:....:......... Fun"rBI
.....:....
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Occupation of Deceased...... ~........................................ Social Security No ............................................. .
Passenger - Cars~ ............::................: : ~ .: ..... . Pall ·.Bearers' Service.c".c ... :... , ..... ,....... :.... . Transferring Body.................................. .. Opening o~ Grave.................. , .................. . Cemetery Charges ................................... .
Name of Employer ......................... :.............................................................................................................................. .
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Date of Death.... ___ ... Q~.~_~
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Address ............................................................................................................................................................................. . Charge to _________8!".cA.0/.!4_.(rj.<{IIPot;!s.~ Address __________ ._____ .... __ ._ ..____ ..__. _______________ .__________ ._ ... .
_____ .___ ...___ ._______ .__ .....
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Rema ins to be shipped-see reverse for details.
Interment at.. ____ .._____._ .. _~~._.h6.f~!~ ..1~~~~'.t.~~f. ...... -...... ... _ ........._._.~~~.:~~~_.____ . __ .. __._....: __ .__._..... _.....____ . _..__ ...
Lot No ............................................. Section No ............................................ Grave No .............................................. .
Rr m, r k · __.... __ ......
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Clergyman Singers
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Insurance .......................................................................................... FORM !i23!i SUP!::RIOR FUNlrRAL SUPPLY CORP •• CLEveLAND, OHIO.
• .................................................... - ........ ........................................... ..
OdobeA. 22, /96/_ Date. ..................................................
CHECK EA= ITEM AS COMPLETED
FUNERAL RECORD OF Yearly N 0 ...........
N 0 .............................. .. _ . _
1(5......................
Casket
(Style) (No.) Outside Case or VaulL ................ __........__ Embalming Body .................................. ..
N ame..................................... I!llUJ.i:all..!fJ.en1..v.o1e..l!lem:lo/l ............................................ Sex.... J!J..M.g............ .
AddJ:ess...............................................
t.>:!!!:.'0?...fi:0.~.U!!!. ................................................................................
County......~._..... _..._... _._._.. _Township ____ ._____... ____..........................__.... Phone No ...................______ ... _............... ({ro • • " f. un;t !n.i.-Mo ~.........................................Race................... uJui:.'?.......................... Where Born. ......... V?........i\h..................
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Professional Service ...... ....... __ .".. _ ._ ~. _____ ._I I Dr esser .... __ ....___......... __ .__... . Suit or Dr ess .._____ ___ ................................. . Shirt, Collar, Tie...................................... I
.,..---.-...I Hair
Date of Birth...... 'j.td!f.J~
.....l8..8.;;,................................ Age...............( ..79. .......................................................... . Years) (Mont hs ) . (Days)
Shoes $...................... Hose $.................... .. Underclot hes ............................................
.__ .. . .. . ....... .. ~... -......~~.~;~::::::::::~:::::::::::::::::
!::l~~:~.~::~~~:~:~::.:;.~~;~~:~:~~·.~·.·.·.·.·.·.·.·.· ~~ ~.~~:~~~~
Door Spray ................................................
Husband, Wife or Child of .......................fl..l!Jll.i).e.j)j~1L.............................................................................. ..
Gloves $.................... Chairs $.................. .. Flowers $..................Palms $................. .
. !!!.~~. ......... ;:.............Addr.ss .....(..~~..............~~................. AlP1e .L . . . .. . . . .. Fat h. r s Name....... ""&7. .. . ........ . . . . . .... _. _.....BlrthPlace.............................................................. .
. Cremation ................................................ ..
Addr. ss ......................._....................................~.... t~.'0? Closest Relative....P.1:!::':!.~ ... t.1E~ ,
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Mother's
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Maid.n~ame ...... ,.:.;.::.: ::::......:~::t=.: .......::...;..........BirthPI.c• .:.........................................:..:...............
Cause of Death.~.q.. ~........Contributory ...............p " " ""''''''''''''''''' ''''''''''''' Date of Death ........ Qc!£k~ Hour........ :.~.9............:..
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Place of Death.... Q1!.'!:'!~C!. ..Ij'?:1~ .................... :HoW Long III? ......(g...~:.: ....................... .. Physician....
I2&...J;,... jj,....29.~fl.........................................AddJ:ess.......(p.&.4.v.ill.~.../fl.j,A'!'!?.IJ!.Id,.......
Newspaper Notices ................................. . Telephon. and T.I.gTaph....................... . . Ambultinco ...................................:.......... .. ........... F uneral Coach............................................ Passenger Cars ......................................~~ .. io •• • • • • : • •• P all Bearers' Service............................... . Transferring Body.................................... ~
Opening of Grave..................................... . Cemet ery Charges ................................... .
&7n!!. .... .c~.'!!!!,. ... . . . . ... . Social Security No.!i.pg.:~..Q.5..=.fo..~!.. ...
Occupation of Deceased .......
Lot ............................................................ .. Misc. Transpor tation................................ I
Name of E mploycr ___.___ ._________ .__ ....................... _....__..__.._.................. _........__ ............... ___ .__ ._____.__ ....... ___ .. __ ........______......__ Address .. ________.. _____ ...................................__ .. __ .._........ __ .__ ______...___ ..... _.. ___ .... _._. ___ .. ___...._____.______.___ ..__..___.. _______________
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_ _ _ _ __ __ _
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Shipping Charges .................................... Clergyman ............................................... . Singers $................ Org anist , ................. .
_..........
3"c:2e!dr~ed
tv.i.d.o Char ge t o______ ____ .__.___o/.....______ ... ___.__ ... _______ .___._______.. ____ ..___ .. ________...___.Address ____ ..._________._ .. _____.__ ..........__ ....._............... __... tv.i.d.o.w
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Remains to be shipped-see r everse for details.
Interment at.. ............ OJgp.j~Qd
..Cf!!Jl~'MJ..j ........................................................._...........................................
Lot No........... ______ ..__ ...................... __Section No..___ .... ____________.__ ....................Gr ave No .....___ ..._...................... _______ _.....
R. m e r k- ..........................1542..Y/h.e.cd..:J.t:h•...S.parJ:an. .. mppe/1.. ..dwded ...................................... ..
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Lodges
D Pall Bearers
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Inf ormation Given To: Rela.tives Musicians
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Attended To: Death Certificate P ayment Arranged
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Clergyman Singers
Permit Bill Rendered
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Insurance ........................ .................................................................
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F OR M 52 315 SU PERI O R FUNER A L. SUPP1. Y C O RP •• CLEVEl. A ND, OH I O.
