Date. .... Ap.~11....
!l:......1...9..6.9_
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF Y.arly No ............
.!t.5......................
Casket "'Ji.l.".R""'.•"<..\
Name. .........................................B.en,Jamin...JT.erno.n... Philllps ..................... se:x........ malfl ......... Address.......................................................Gar.fl.e.ld..... Ar.!l;@.!:'l.;l..~.............................................................
Professional Service ................................1 ............1..... . Ha~ D.."se.r................................................ Suit or Dress ................................................ 1....... ........[. .. .. . Shirt, Collar, 'n'e ........................................ I.............. I..... Shoes $...................... Hose ~....................... I............... I.... .. Underclothes ....................... _................... 1............... Door Spray ................................................ 1.........·.... 1.... ·· Gloves $....................Chairs $.................... 1................ Flowers $.................. Palms $................. . Cremation .................................................. 1............... 1·.... · Newspaper Notices ............................. _... 1.............. 1...... Telephone and Telegrallh ........................... Ambulance ................................................ 1......... •.... 1...... Funeral Coactl .............................................. 1 .............. 1. .... .
County.....Bar.r¥........................Town.hip ..................................................Phone No ............................................ .
I..............
Where Born........... Da.1J..aa,....T.exas.................... _ .................................Race............. Ylb..:t1i.I'L................
Date of Birth....... .J,anu.a.r.v.....
13......l~.8.1 .............Age..................T!I... ....................................................... (Years)
(Months)
(Days)
1-2... y..ears....................................................................................
How Long Resid.nt in COmmunity................
Single........................Married. ..... ma:r..:r.l~owed ....................... Divorced ...................... Child............................. Husband, Wife or Child of...............................lIlel11e... Banka.................................................................... .. Address ............. ~ ...............................................................BQ)J.1i.i:. ...
#.?..........g.~;r.r..*.~:J,.a...,..... Ark.:.~I}~.~~...
Closest Relativ.....lIlellie... Banks....................................Address.................................................................
i...............i.......
Father'. Name......f!j.Jl\Q.n. .. P.h1.11;!..P..~............................ .Birthplace ............................................................ .. Mother's Maiden Name..........N.ann1.e....\Y..1J.s.Q.11 ............Birthplace .............................................................. Cause of Death ................ __ .____......... __.___ ....................... ___.. __ ..... ___ ...Contributory...... __ ...........................__ ....... ________ ...... Dat. of Death .......A,pnL.4...... 19.6.Q............................... .Hour.....................~ ...!i'....M .,................................. Place of Death ........ hQme. ..........................................................How Long Ill? ................................................... .. Physician ..........DI'......Q.h.as.....R .....13r.o.Wn..................... Address...................C.as.s.1l.111e......Mo,.... Occupation of Deceased. ...........f.armer................................ Social Security N o....:I..Q.Q ..·~ .. Q.'1..:.:l.Ii:..() Name of Employer .... _________ .__ ..................__....... _... _...................................................................................................... . Address ............................................................................................................................................................................. . Charge to...................w.ido.11L.,and ...Inau:r..anc..e ..........Address................................................................... Order Given By.......... 1V.ldQX{....an!l.... ~.9.n .........................Address ................................................................. . Date
of
Funeral ....Ap..t'.i1...7-.r....~9.6.Q ................................Time..................2 ...P. .• M.....,D.e.n1i...................
Passenger Cars·········································· I....·..·...... I..... . Pall Bearers' lServl
+.....
Place of Funeral Servi
;.nan9..li...................Call for ! ........... ...,
D
Total AnnoclDt.................................... I---+_
Remains to be shipped-see reverse for details.
Interment at....................DeBt. ...G.e,!IU~t.a.l:'Y........................................................................................................
Lot No ............................................. Section No ............... _............... ;............Grave No .............................................. . Ramarks .............. -'-Sp.ec.ial.} ....... lg... ga. ... ai~v.er .... s.lJ.adad ...b.lu.e.... S.aa.;!.aI'.... Ma.l.l...
..........................P.e..+'.f.e.9..1;.*g.!}....~g.;r.JI1.e.:::.'N.l!,.~.t..El.... ~E.El.P~.;Il:~ElI:';'?I'................... .... ..............................P.lat.ed..M'R..........eP.l;:~MU.e.),.a......9.1?,.f3.k.:t3.:t;...MJ.g.9.?.. ~ ........... .......... FORM 5233 SUPERIOR FUNERAL
8 U ~~LY
CORP •• CLHVI! L AND, OHIO.
Information Given To: 0 Relatives 0 Musicians
o o
Lodg'es Pall Bearers
o o
Death Certificate Payment Arranged
Attenrled To:
o o
o o
Clergyman Singers
Permit Bill Rendered
A12!'.P:...!±..... J:9..§.9...
46
Date. ........
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF
No........ _.. _.........•_.._ _
Yearly No .... _......
....... ···1 Cask.t ~.Y.aJ.• l:t~C.l9.:th.lng.........
_4.6_ ......_......_...
Name....... _.....................Erana1.B....El.ay. ...Rur.at .. _................................................. Se:x............ male. ..... Address................................._.... p..ln~y."-U.~.•....MJ.§.~g.l:!;r.J........ j.9.y..9.)..9.~~ ..L............................. COunty.....McDoonald........_...Township......._............ _........................... Phone No............................_.............. . Where Born............._..._•..__ .M1.s.aO.lIr1................ _.._.................................. Race ................. wh1.:t~ ............... (
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Date of Birth. .....S.~1?:!i.~.!!!Q~.r..._+.9-'....J,~.Z9........... Age ........._...........~g (Years)
......................... _.................. _....... (Months )
(Days)
How Long Resident in ·Community........................................................ _.... _......... _...._......... __ .________ .... ____ __. __ .____.___ .... . Single....................... .Married. ....................... Widowed ..:'!'!.;!,9,9.lV.!'!.clJivorced...................... Chiid ........................... . Husband, Wit. or Child oL .._........................................................ _........_... :............................................................ . Address ......._...._........ _.._...._.. _...._............................................................ ___ .... __....__.....................................____ ..... __ ....... Closest R.lativ•. _ ..._..RoY-... Hur.s.t...... _...............................Address......... ~.e.~.a... ~p..t.l.pg.~ •....A..k Father's Name...... Andraw...J.aJllkaQn .. liur.at .. _.....Birthplace. .._............................_.......................... .
Mother's Maiden Name...........c.a:tl:l.e.r.1D.e....Ta'g9.~......Birthplac~... _...................................... _.. :..............
Cause of Death ...............................................................................Contributory......................................................... .
!±•.....l.9.6.Q...................................Hour ...........-.........JtJ'..,.M..,................................
Date of Death....AJ;l.:r.1l....
Place of Death·· ....M.1-S.\lOlJX'.l, ... S.tat.e.... San_···········lIow Long Ill! ............................................... _... . Physician .......................................................................................... Address ................................................................. . Occupation of Deceased. ..................t'.ll.;r.m.e.~....... _................ Social Security No...............g~+.!9'!!g ........ Name of Employer........................................... _... _...... _................................ :............................................................. . Address ............................................................................._............................................................................................... Charge to............ Roy ... Hur..a.t.."..Sad.le...Y.o.i.mg ...... ...Address .................................................................. . Order Given By................~I.... . . .......... . ........ . ..........!!..........................•Addre'ss .............................................................;, .......: Dare ofFu"e~~......... ~~.i~....
1:r....l~~b:Q ..........................jrime.......... ~ ... j~ ..Jf. .• M.•.... _.............~
P lace of Funeral Se'evil'e.... _......... _..JUl1,J.()U•..I.<.IlJWlliC!l... .......................:...................................,
•
(Style) (No.) ·········· .. 1Outside Case or Vault............................. . Embalming Body ................................... . Professional Service ...................... :........ . Hair Dresser............................................. . •••••••.• · •• 1 Suit or Dress ........................................... . ··· .... _ ... 1 Shirt, Collar, Tie..................................... . ············1 Shoes $...................... Hose $..................... . •• · •••..•... 1 Underclothes ........................................... . Door Spra.y ............................................... . Gloves $.................... Chairs $.................... 1 ············1 Flowers $..................Palms $................. . •••••...•••• 1 Cremation ................................................ .. ············1Newspaper Notices ................................. . •· •••••••••• 1 Telephone and Telegraph ........................ • •. •........ 1 Ambulance ................................................ ············1Funeral Coach ........................................... . _ ••••••••• • 1 Passenger Cars ........................................ .. Pall Bearers' Service .............................. .. .....•...... 1Transferring Body............................. ,.... .. Opening of Grave..............................._... .. •••• ·· •••••• 1 Cemetery Charges.................................. .. Lot .............................................................. Misc. Transportation .............................. .. Shipping Charges ................................... . Clergyman ............................................... . Singers $................Organist $................. . Cash Advanced ......................................... .
~=-! ......l:!.?:±.~.~... J'~ ..................................
Clergyman ......... _Rey..•.._J.Qhnny_...l'l.1.l11M.!L..........Call Ior: ........................:
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-_··_···1·············································......................... Total Amount.. ................................. I . - - - - -
,.-
Remains to be shipped-see reverse for details.
Inrerment at................. _Eaz.al._G.r.e.en ...C.eme.t.er.y................................................................................ Lot No ............................................. Section No............... _............................ Grave No .............................................. . Ramarks .. .... ............
;!.gQt.1:'....J,.~.~....~....~§e'1l... ~~.ct....13.:.??z..~ ... ?().I'lll:~.~~':l~.....................
o o o
Lodges Pall Bearers
Information Given To: 0 Relatives 0 Musicians
D Clergyman
o
Singers
Attended To: Death Certificate Payment Arranged
D Permit D Bill Rendered
........................................:r.Q.!:l.e..t .
o
......................................... .Qg.ml~.r..~Y.P).El....g.a.~~~.~.._.. _C?.()...................................................................
Insurance........................................................................................._
F O RM 0231S SUPERIOR FUNERAL SUPPLY CORP. , CL8YELAND, OHIO.
47 FUNERAL RECORD
CHECK EACH ITEM AS COMPLETED
OF Yearly No ...........~l.
No.........................._ __
.......................
Name.......................Luay. ....BQ11n.....................................................................................Sex............f.J:!ma.le Address.............................J.enk.1na....... Ml.s.s .Q.u;r.l.......................................................................................... COunty........ Bar.r.y.. ...................ToWDship.................................................. Phone No ............................................ . Where Born...............M"'.§.~9.y...!'..~ ................................_ .................................Race.................... ~J:1.?:-.~ ~
.. ............
Date of Birth. ........................................................................ Age.................................................................................. (Years) (Months) (Days)
How Long Resident in COmmunity........... ____ .____ __ ..................... _.......................... _..................................._..... _....... _.. _ Single........................Married. ....................... Widowed.........\OZldo.'1lB4rced...................... Child........................... . Husband, Wife or Child of..................................... NQ.ah...Sol-1n ..................................................................... . Address ..............................................................................dec.eased ...................................................................... Closest Relative.......H.ugh... B.o.l.1n......................................Address.... Jl~!P:~J .......Q.~;p,f..................... .. Father's Name......J.Onas...l'l.11son...................................Birthplace............................................................ .. Mother's Maiden Name... .AD.g.~J~.'li.!i.~ ...)'(JJ,~y............
Cause of Death ..~.ct.~
irthplace............................................................. .
. i.Lt.,t; .... .........Contributory..........................................................
Date of Death.......... iP.r.l.L.5 ..... ~9.6.Q.............................Hour ................... .1. ... Place of
.4...,.. /y).. .......................... Dea th ......sUns.et...llall.ey.... Res.t ... HOm.eHow Long III? ............. ..2. ...~ .............
Physician .........nr..... ,G ..... A. .....P..ur.v..e.a............................ Address ............Q.a.!?J?y.J.x. ....~......MJ.!?9.Q.y.r 1 Occupation of Deceased. ............. ho.uaew.l:fe ................... Social Security No ............................................. .
Casket
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__....... ______... __ ......................1 (No.)
Embalming Body ....... __ .__ ........ __ .......... __ ... 1 .. .......... ! Professional Service __ ............................... 1 .. ____ ...... \' Hair Dr.,'ser........__________ .............................. 1 ............ Suit 01' Dress ............__ ........__ ...................... 1 Shirt, Collar, TIE, ____ .. __.......................... __ ... I Shoes $.... __ ............. __ .Hose ~ ...................... I Underclothes Door Spray ............____ . ____ ................... __ ....... .. Gloves $....................Chairs ~...................... I Flowers $.................. P.lms Cremation ____...........__ .................................... 1 Newspaper Notices .......__ .........................__ .1 Telephone and Telegraph ........................ Ambulance .............................................. .. Funeral Coach........................................... . Passenger Cars ......................................... . Pall Bearers' Service ............................... . Transferring Body ................................... . Opening of Grave..................................... . Charges ................................... .
Name of Employer. __ ..... __............... __ ........... ____ ._.. __.......................................... _....... _.... _..... _....... _.... __ ..._...................... . Address ............................................................................................................................................................................. . Charge to ............ ch.ildr.ell ....................................................Address ........ __ .. ____ ...................... __ ......... .. Order Given By..............chl.J..d.r.e.n...................... __ .. __ .......... .Address .. ____ ....... ____ ... . Date of Funeral... .......... ,April...g .......19.6Q......................Time .. ____ ...... .1 Place of Funeral Sernce.................Clio....Gb.ur.c.h.............................. . Clergyman ....B.r.Q ......Gar.e.l.d....9.t.UIllP.t.f.....,................Call for? __ Address .................. ____ .Q.r.M"'.~.... M.~.§ .§Q.~r.-*- ........................................
D
Remains to be shipped-see reverse for details.
I
Interment at ................. _........ _........ _.............................................................. . Lot No ................................ _........... Section No............... _......................... ~ .. Gr, Ramar ks __ ...................2.JQ-~... 292 ... I:v'O·I'Y __·.Bronz.e... ahaded ..
.__ .. __ .. ______ ............................C.an.dlellght...MaUas.6.e.... T.+.'.9.Y. .. __ .. 1 .. __........... ____ .... ____ ...... __ ..............lfu,;l..t.e. ..,g9.J,.d....g.~~.!I!9.ml .. $;!..Q)Y__,....Q:~
.. __ .__ ................ ______ .. ______ .....Q!?gr.:.. :~.~.y..t!:;J,.~....g.8.:.~~.~.~...9..~..~................ FORM sa3S SUPER I OR rtUNE R AL SUPPLY CORP .. CLEVELAND, OH I O .
T otal AnlOu:nt................................. ) <--:{7 ' Information Given To: r~
48 Date... _....•.
AP.r."-.1._I •....1.2 60
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF· Yearly NO•... _.n•.. _..bI,.a..... _.. n.._...
N 0 •••. _ •• _ •• _ ••••.• _ •• _ . _ . _ _
Name. ...... _... nnn.n .. n......_... DOlphnnG.r.e.eu ... LJn.D..n.n .. n..... nn .. nn ... nnn .... n.. n..... n.. Sex.nn.n.Ip,?-.±.~n ...... .
Address ... n.. n.. nnn ........... n..._..............Q.§:.!'!.fi.Y.!J±~, ....MJ.e3..I?'?..':l.~.1....n............... nn .... nnnn .............. n...... n.. .. County........ Bar.r.Y-............... _...Township ....... _.._........_...........................Phone No ............................_............... Where Born...............Arkanaa.a................ _.........._.._ .... _...........................Race....................... ~h.:t.:l!? ......... Date of Birth.....NQ.ll.eJllQe.~... l.3..L-_l$..'_I............ Age........._._.. (Years)
..I.?............................_.................. _....... (Months)
(Days)
4-...
How Long Re.ident in Community......... .Y.J;l.n!n ....... Father's Name......Ma.r.ion..Llnn ........................... _.._.... .Birtbplace... _............................_.................. _...... .
(Style)
(No.)
Outside Case or Vault.......................... __ .. .. ........ _./ Embalming Body .................................. .. ............ Professional Service ............................_.. . ............ Hair Dresser ........ _._ ................................. _.
............ b.ixlOXbse ·,J·acket....................... Shirt, Collar, Tie ..................................... .
Shoes $....... _............. Hose $..................... . Underclothes ............. _............................. Door Spray ............................................. _.. Gloves $.................... Chairs $.................. ..
Flowers $.................. Palms $................. . Cremation .................._.. __ .... ____ ... _.. _........... . Newspaper Notices ............................. _...
Telephone and Telegraph....................... .
......
Name of Employer. __ .______ ................................._... _.... ____...,........................_........... __ ................................................... .
Lot ............................................................. .
Date of Death ... _..Ap.r.il...-1-•....1.9.6.Q................................Hour.............. )..9. ...~ ..,.M.,.................................... Place of Death.........l=.IG-me............................... _.........................How Long III? ............ }Q ...m1nu.t.e.a........ Physician..........Dr.•....G.•....A.•...P.ur.Y..e.S............................ Address......O'§,.~.§.y..P,)&•.....¥..1..~.s..o..~;r:J Occupation of Deceased.........t.r.u.ck .. -'ll::::t.y..I!.!L... _........ Social Security No..... 5~.~~.J,.~5:J,~.9.
Address ............... __ ............. _...................................... _...... _........................................ _.. _......................_.. ___ .......................
Charge to..... .Mr.s.......W .. ....A.... Rag.e.r.s .......................... _.Address ...Qa.!l.~.Y.J.+.J..~ ..... M,1,.(!.~g.wrJ.... Order Given By...............~........ _.................................._..................A.ddress ..................... _................___.... __ ................... Date of FuneraL ........Apr.il... l.O.~ ....19.6.Q......................Time .............................. f...,.~..,...................... Place of Funeral Service............. _......C.ul'l_e.;r..~.Il_ ..9.lla.P..~..+........................................... '-.. .................. . Clergyman ....... Rev..._..Bay.mon.d..B.1ac.k......................Call for! ............ Address..._..................C.a.s.ay.ille.......Ml.§.1'l.Q .1J.r~ ............. ~.. _..
.3. ...
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Misc. Transportation ........................ _.. _.. .. Shipping Charges .................................... , Clergyman ............................................... . Singers $................ Organist $................. . _.......... Cash Advanced ......................................... .
..Sa.l.e.S ....Tax··......··....·..·.. ··........··......·1 Total Amount.................................. ·
Remains to be shipped-see reverse for details. Information Given To: o Relatives o Musicians
I
Interment at................ -f{t.•. _.P.le.aa.ent... C:.eme..t.er.Y..
Lot No ............................................. Section NO •.............. _............................ liravt:l
Ramarks ......................#225....O'.Qp.p..~.r [email protected]:g..~9: ... 1:>:r.<:>.Il:~.~ ... f31;~~...
t:. CJ.J:l..~.............
Rostan satin twill interior-sprayed hdw. ................................................................................ _........................................................................................................... \
1
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Ambulance ...._.......... _............................ _.. . ............ Funeral Coach .........._................................ _ Passenger Cars ........_................................ . ............ Pall Bearers' Service ............................... . ....... __ ... Transferring Body_ .................. __ .............. . Opening of Grave..................................... . Cemetery Charges .................................. ..
Mother's Maiden Name..._.J.ana ... Q.lln."!!.9Jl..................Birtbplace... _...................................... _................ . Cause of Death........ Q.o.r.Qnar.y.... Q.Q.QJ...lJ..);!.~.Qn.............Contributory..........Qg.~9.1}.?-.~Y. ....?g.±.~~g sis
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Casket
: :: : : : : : : : : : : : : : : :: : : : ::::::::~:~~~~.~:::~.~.~:~:~::~=:~:: :~:~: : : : : : : : : : : : : : ::: : : : : : : : : : : . \ \ FORM 152315 SUPERIOR FUNERAL S U PPLY CORP., CLEVELAND, OH I O.
o o
Clergyman Singers
·' 4 <\.ttended To:
o o
Permit Bill Rendered
Ji;e. Date......AP-r.1;L$.......J..9..Q.2_
CHECK EACH ITEM AS COMPLETED
FUNERALltEC6RD'OF '
!:!1.........................
Casket &....ser.:v.1c.es........................ (Style) (No.) Outside Case or Vault............................ .. Embalming Body ................................... . Professional Service ................................ Hair Dresser............................................. . Suit or Dress ........................................... . Shirt, Conar, Tie ...................................... Shoes $......................Hose $...................... Underclothes ........................................... .
Yearly No ..........
No....................
Name. .......................................Har.r.lson... A•.... Bpain..............................................Sex.........ID9.-.:.l..! L...... Address .................................................Q~.!HlY.JJJ..\'!.I.....M±.B..B..9.t!-..I'J.:.............................................................. COunty......?.~r.r.y.
.......................ToWDship......~1J..t..t..1?!.f~.~.~~.........Phone
No ............................................ .
Where Born...................Ml.s.6.Q.ll.rJ.,.............c .............. _ .................................Race....... ~h..j,.1;.~.........................
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l.S.9.a............Age.......................... g.L.............................................. . (Years) (Months) (Days)
Date of Birth............Au.gWl:t....l.Q4.....
How Long Resident in COmmunity........................................... _..........._.............._.... _._ .......__ ._____________________ ..............
~~::esS;~~~.:::::.:.:::::~~.;;;~..$::::::::::::::::::::II
Single....................... .Marrie
Occupation of Deceased. ...........;far.me.r. ............. _.............. _Social Security No ..............................................
Flowers $.................. Palms $................. . Cremation ................................................. . Newspaper Notices ............. _................... Telephone and Telegraph ...................... .. Ambulance ................................................ Funeral Coach........................................... . Passenger Cars ......................................... . Pall Bearers' Service .............................. .. Transferring Body................................... . Opening of Grave............................... _... .. Cemetery Charges ................................... .
Name of Employer........................................... _... _...................................................................................................... .
Lot ..............................................................
Address .........................:......_ ...............................................9..~.B..s..y..l.:.~.~.~.1 ....~~.~~'?.\l.r.:.~................ .............. Closest Relative....Mr.S .•....Be.8.6.1e....SP.a.1n ..................Address ..........G.§.!?!!.y.±1J.@ ......M±.B..B..9.!JJ·l
Father's Name......ll,o.OO.r.t...S •....Spa.in. ....................... .Birthplace.................................~ ........................... Mother's Maiden Name.E.I1JJJ).~ ...
);l!J.r.!L...................
m
...... ...
.Birthpl~;e..............................................................
Cause of Death........ P..ulIJlQnarY.....Emp4.Y..!l.~.!!!§..........Contributory.....~n.~g,~~~.1!.\'!....9.iSy.p..~Jla t Date of Death.......
M.r.J.*....~L ..l.:~.?g ...............................Hour...............2.;)g...~.~ ....~.~.........................
lon-······
............
Place of Death ................h9.!!1.~................................................... .How Long III? ..................................................... Physician.......... D.r..•...Cha.s.•... .H .•... P..r.l.c.e......:.....:.........Address.......Q.~.!':I..B.y..LU.~.•....M.~.B..!?().~.rJ
Date of Funeral... .... Ap-r..1.1.... J.'O'•.....l9.60.........................Time .................. 2.t.).O ... 1'.~M •.........................
Misc. Transportation.............................. .. Shipping Charges ................................... . Clergyman ............................................... . Singers $................ Organist $................. . Cash Advanced ........................................ .
Place of Funeral Service................. Bu.t.t .er.f.le1d .. l?ent.eCQ.S.t.al. ...Ch~.ch ............................
.......3al.e.s... Tax...............................
Address ............................................................................................................................................................................ .. Charge to ............ WidD.w... and ... lnaurance ................Address .................................................................. . Order Given By...........F.amily ............................................... .Address ................................................................. .
Clergyman.......Be:v.~...Er.ank. ...Ea:t.Qn ............................Call for? ................................................................
!
Address..............................MQ!J~.1!.1;.... .I.... .M.j,~J1.CJ.11.lC.L .........._..~.......................................................................
D
Total Amount...................
Remains to be shipped-see reverse for details.
Interment at....................Mt ...l'leasent ...C.eme.t.~.................................................................................. Lot No .............................................Section No............................................Grave No .............................................. . Ramarks ..................... #..?_~5.....~.Uy..~.r ....[:!l.l.E!:9-.El.4 ...l3:':l.I}Ill.~.~.~.~....8.~~.~.~.J:
...~?~ ......................
.......... .......................l.y.CJ.r.Y......~.?,1.j,.~.....~.g.J,....l.:l'!.t.~.~.l,~r.:=-./;IP.r..!l.~~.d: ..£lC!,\\T.~ .... ....... ..........................................J!P..I'J!?-Ef.~~.;.!,9:. .9.~.§.~~.~...~.~~.:....g.~.~......:............... ............................ FORM 52315 SUP.RIOR FUNERAL SUPPLY CORP., CLEVELAND. OH I O.
'11
Information Given To: 0 Relatives 0 Musicians
o o
Lodges Pall Bearers
o o
Death Certificate Payment Arrang-ed
Attended To:
Insurance .. ...f
.... . .... .,. ... j
o
o
o o
Clergyman Singers
Permit Bill Rendered
CHECK EACH ITEM AS COMPLETED
FUNERAL ' RECORD ' OF ' Yearly No .... _,,_,,_,,~,,~.._..•
No•...."._...•.".,,_.__. _ _
Name. ...... _........_............__.....L1ml
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Date of Birth.....Ja-n1.l.atl¥-.-J.:? •....J..9.01.,····.······· .. Ag•......-.-.... - .. . . . (Years)
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Information Given To: 0 Relatives 0 Musicians
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Lodges Pall Bearers
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Death Certificate Payment Arranged
Attended To:
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Clergyman Singers
Permit Bill Rendered
Insurance ......................................................................................... .
(Boone) CHECK EACH ITEM AS COMPLETED
FUNERAL ' RECORD OF No......................._ ..._ _
'Yearly No ............ _
Name.......................................~!!.J,... ;e..Q.g.g.~.r.~ Addres ....................................
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Cask.t ........................................................ $................ .. (Style) (No.) Outside Case or Vault......................:.......................... . Embalming Body ....................................................... . Professional Service .................................................... - Hair Dresser................................................................ .. Suit or Dress .......................................................... ..... . Shirt, Collar , Tie .................................................... ...... Shoes $...................... Hose $...................... ................... . Underclot hes .......................................................... ...... Door Spray .............................................................. ...... Gloves $.................... Chairs $...................................... .. Flowers $..................Palms $.................................... .. Cremation ....................................................._......_....... Newspaper Notices ................................................ ...... Telephone and Telegraph....... _.................. _.............. . Ambulance ................................................ ................... . Funeral Coach ............................................... _......... ..... . Passenger Cars ............................................................. . Pall Bearers' Service........................................... _...... . Transferring Body....................................... :.......... ...... Opening of Grave ............................... _........................ . Cemetery Charges.................................................. ...... Lot .............................................................. .............. .... .. Misc. Transportation................................................... . Shipping Charges ....................................................... . Clergyman .................................................................. .. Singers $................Organist $..................................... . Cash Advanced ............................................................. .
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County............................................Town.hip.................................................. Phone No ........................................... ..
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Where Bom............. _...._.._........_.. __ ................_.......... _.._ ...._........... ___ ._____.__.... Race __ ............................ __ ................
IY:...................................................... . (Months) (Days)
Date of Birth.................._ ....................................................Ag...................... (Years)
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How Long Resident in Community......................... __ ............................ _... ____ . __ ........ ___............................................... . Single........................Married _____ .............. __ .. Widowed.....__ ................ Divorced.. __ .................. Child........................... . Husband, Wile or Child of.......................................................................................................................................... .. Address ............................................................................................................................................................................ .. Closest R.lativ................... _ .........................................................Address ......................................., .......................... Father'. Nam.................................................................................Birthplace.............................................................. Mother's Maiden Name... _............................................................Birthplace..._........................................................ . Cause of Death ...............................................................................Contributory.......................................................... Date of Death............ April...9......19.6.Q..........................Hour....................................................................... . Place of Death ....... Jt
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Place of Funeral Service............. McQ,U4'l-8ll.. .cha.pe~ .................................................................................... Clergyman........................._.................._.........................................Ca11 for? ...........................................................•._ Address... _............................................................_ .............................._.._.:......................................................_...... _.._. (
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Interment at......... Muno.e.y: ... Ch.a.pel....C.eme.ter.;y.................................................................................... .. Lot No .............................................Section No............................................Grave No .............................................. . Ramarks ................................. _........................................................................................................................................ ..
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No........ _.. _.._.. __
Name....... _........ _............ _...Da'lid...W.e.ale,Y. ... ahul..t.z............................................. se:x.....mal.e............. Address....... _........................ _.......~.~.c:lY.
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.........._............................Age.........___...5.l.................. _............................_.......
Date of Birth........9."'~"'-l.81g
(Years)
(Months)
(Days)
How Long Resident in COmmunity.............................................. __ ....... _... _... _..... _...... _...............................__ ..__________ _ Single........................Married. ..mar.r.leiWidowed ....................... Divorced...................... Child ............................ Husband, Wife or Child oL ........................Lo.ttle.... Shult.z. ....................................................................... Address ............. _........ _.._...._........ _.............................p.).l..~gy4.....M,t.§.!?Q.)i,;r.."....................................................
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Father's Nsme......._1] ok nO.Vill......................................_ .. _ .....Birtbplace_________._ .. _...._.......................................... Mother's Maiden Name................lJn:!!:.u,9.y..P... .........................Birthplace ..._........................................................ . Cause of Death....a.Q.r.!';ma.n ... Th.;r..9.~l?9..!?!!L ..........Contributory...MA;r..1i.~;rJ-~~¥l~.ti¥U.~ee Date of Death... _.Apr.1~...1!±.•....19.6.................................Hour....... 9A.•.....,................................................_ Place of Death.... h.o.me ................................... _........................ .How Long Ill? ..................................................... Physician .............D.r..•....ChaJL, .. JL.... f..;r..".g.~ ................... Address........... .9..!!&s.y.J±.*.~
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Occupation of Deceased..................r.atir.e.d...................._Social Security No ............................................. . Name of Employer............ __. ____ .___ .___ .. ________. __ ... _... _................................... __........................ ______ .___ ........_....._..... __ ..... ___ ..
············1 Casket ··-&·· ·~·.·bQ*···························.·· (Style) (No.) ············1 Outside Case or Vault.............................. Embalming Body ................................... . ············1Professional Service ........................... _... .... ·· ...... 1 Hair Dresser............................................ .. .··········· 1 Suit oX~ ...cl.e.anlng.............. ············ 1 Shirt, ~e ............. :....................... . ············1 Shoes $......................Hose $..................... . ·········· .. 1 Underclothes ........................................... . Door Spray .............................................. .. Gloves $.................... Chairs $................... . ··········.·1 Flowers $.................. Palms $................. . •••••••••. .. 1 Cremation ................................................. . ·············1Newspaper Notices ............................. _.. . ···.·······. 1 Telephone and Telegraph....................... . . ........... 1 Ambulance ............................................... . ············ 1Funeral Coach .......................................... .. Passenger cars ..........................................1 Pall Bearers' Service.............................. .. ··· ... ·.···· 1Transferring Body.................................. .. Opening of Grave ............................... _.... . •••••••••••• 1 Cemetery Char g es ................................... .
............ 1Lot ............................................................. .
Date of FuneraL ... Ap.r.ll._.1~.r.... l~6.Q ..........................Time...........:........... } .. .P..•M.•..............................
Misc. Transportation............................... . Shipping Charges ................................... . Clergyman ............................................... . Sing'ers $................ Organist $................ .. Cash Advanced......................................... .
Place of Funeral Se],..i"e...._........_.....u ..Ll.l.Y.I"l:...~.Il._.:>'.IJ,al;le..J.. ...........................................................................:
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Clergyman ......... _.. Re.v..•...Ray.m.ond. ..B.la.ck................Can lor !. ............ . .............. . ......................,
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Total Amoun ~..~....................... 1 Remains to be shipped-see reverse for details. Information Given To: o Relatives Musicians
Inurmentat........ _........._QaJ"..J[jJL:L... U~~.et;ejry ......................................................
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Date. ........Ap.r.ll...l.9.•....l.9.6.Q
FUNERAL RECORD
OF Y~arl;v No ...._......_.., ...~~._._
No........___.._.._ .____ Name. ......_......................_..........Q.9.h.~ .~......
p...~....!f~.~~.~...........................................:...Sex..ll!~.:L.~................
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Date of Birth. ...J:uJ.y..-}.Qr-..l.S1$.......-... -............Age........._._ ... .7..~ .............. _................................_....... (Years) (Months) (Da;ys) How Long Resident in COmmunity........................................... _........... _.................................................................. .
Single....................... .MarriedJlla.r.rled.Widowed .......................Divorced...................... Child............................ Hu.band, Wife or Child of........................Mitt.1.e....W.Qmac.k. ...... _............................_................................... Address ............. _........ _.. _...._.. _............_......................P-.ur.~.•....M1sso.ur.1 ................................................... C1o.est R.lativ8.-....Mr.s.•....8p.anC.e.r....Wal.J.a.c.!il.......Address .................. .Q.~.§.§.'?J}-.;l,~.......~'"'!l § 0 ur :Ii Father'. Nam•.....J:ohn... A •....WOmac.k. ................. _.._.....Birthplace... _.........................................................
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Mother'. Maiden Name.......Bl:lo.da....Bennett................Birtli.place..._......................................................... Cause of Death ........ O"nge-8-1>j.,.e...heart... 1'.11~butory...p.u1m.onarY-... Eie.ms. ..... Date of Death... -A,pI!11...1.9.• ....1.9.6Q................................Hour ..................9..tl.Z....A.•....M.,....................... Place of Death...St...'l.1llC.ent.ts. .. Ho.Ep.t.1a.l. .........How Long Ill ?..................................................... Physician .....·.DI!·•....~-8-s.~ .. .H.•... P.rlce ......................... Address ......Q.a.~.§y..1J.J..~ ......¥9.. f..._ •.•••• •. ••• Occupation of Deceased........ .f.armar................................. _Soeial Security No .........__ ......__________________________ . Name of Employer________________ .______________.______ .________________________________________ .__________________________________ ..____________________ ... _____ ~ Address _____________________________________________.___ __________.______ ._______________ .. __.. _....... ____________________________________ .______________ ._______________ .
Charge to............M1ttle ...WOmac.k. ................................_.Address ...fw..9Y..•....M.~1!.§Qg.r.-1,.... Order Given By _______ .!t ___________________ _ I:1_______________________________._____________.Address _______________________ ._________ .._. _______________ .
Date of Funeral... ....Ap.r.j.l_..22,.... 1.~6.Q .........................Time ..................2 ...1'.•.M.•................... Place of Funeral Service.............-Oulv:@.l;'_!.a....chapel..................:........................................... Clergyman........._Re¥_.··--Le-J>-O¥-.·.J·OOnSOn..................Call for? ....................................... Address......................P .ur..dy., ....M1ss.Q ll.ri ..... _.............:.... ~.............................. _...
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Remains to be shipped-see reverse for details. \
Interment at.......... p-.1.W~.-.c.eme.ter..y: .............................................. Lot No. ________________________________.___________Seetion No._____________________ ._. ___________________ Gt
Ramarks·······················#2§-··C-Opp&l'···.shaded...bronz.e ....... . ........................................RQs.e.tan....satln._.1;.w.1l.J.....'"'~.t~.r.1,.().I. Sprlng.:r.1,.ElJ~.. gasket Mfg. 00.
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CHECK EACH ITEM AS COMPLETED
FUNERALREC6'iID OF
No........ _.._.._.._.•_ _ _
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Cask.t ....bOXm.(W.)... (Style) (No.) Outside Case or Vault............................. . Embalming Body .................................... Professional Service ........................... _.. . Hair Dresser.................. __ .......................... Suit or Dress ........................................... . Shirt, Collar, Tie...................... __ ............ .. Shoes $....... _............. Hos. $.................... .. Underclothes ............................................ Door Spray ................................................ , G1ov.s $.................... Chairs $................... . Flowers $..................Palm. $................ .. Cremation .................................................. Newspaper Notices ..... __ .......................... . Telephone and Telegraph...................... .. Ambulance ............................................... . Fun.ral Coach ..... :\;9... Jl,9J~ky.............. Passenger Cars ......................................... . Pall Bearers' Service .............................. .. Transferring Body............. _..................... Opening of Grave..................................... . Cemetery Charges .................................. . Lot ............................................................. Misc. Transportation .. 2 ... tr.lp.s. ..... Shipping Charge. .. ............................... .. Clergyman ............................................... Singers $................ Organist $................. Cash Advanced ........................................ .
Y.arly No ...._.._.._.:f!I. .
Name....... _...........Ar.thur....F.l1.rt;•........_................. _.._................................................. sex. ...........~.1..!L ... Address......................Hae.t.ing.e.•.. _.M1.Un.............. _......................................................................................... COunty......................._.. __...._.._...Township....... _.._....•... _.................... _.....Phon. N 0 •.•.....•... _ .•.•...•.....•_ .•.... .......••
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Date of Birth........J.un.e....2•.....l5.9.l..........................Age............. _....Q~ .............. _................................ _....... (Y.ars) (Months) (Days) How Long Resident in Community............................................................................................................................ . Singl• ....................... .Marrie.L ..................... Widow.d .......................Divorc.d...................... Child ........................... . Hu.band, Wife or Child of...............•.•....•..••....•..•.....•.....•...••...•......._.....•................................_................................... Addr•••............._........_.._...._.._........_............................................................................................................................ . Closest R.lative._...._.....J.ohn...F.J.ut.y_ .............................. .Addres .......... Exe.t.~.ry~.....~l.!i!.§.Q.~.t.. . Father's Name............._.._.... _............................................_.._, .....Birthplace____ ........................................................ . Mother's Maiden Name. _______................................................ ___ ... ..Birthplace... _.........:.............................................. . Cause of Death ................................. _............................................Contributory........................................................_ Date of D.ath... _........ April ...15.......l-9.6.Q.....................~our... _.........'C.......... .. ........... ... ... ................ .. ...... _ . Place of Death.........Ra,st.1ngS.,.. ..M.1nn....................... .How Long Ill ? ................................................... .. P hysician ......................_......_........................................................... Address~ ................................................................ . Occupation of Deceased. ............................................................ _Social Security No ............................................. . Name of Employer........................................... _........................................................................................................... . Address ............................................................................................................................................................................. . Charg. to...................... J.ahn .. Flu.ty................................. ...Addr.ss ................................................................. ..
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Ord.r Given By...........J.1hn... F.l.utY................................. ,.Address................................................................ ..
?.... ~..~.N.I..~ .........................
Date of Fun.raL .... Ap.rll... 21.,.....1.9..6.Q.........................Tim..........:....:.............
Place of Fun.ral S.rvic...._.....Jl,Q.Q.l!;Y.....g_Q.!!!.f..2ft.~ ....g.~!!l.~.~.E?I.'l.......................................................... _.
.....Grav.EI ... Equlpment.................
Cl.rgyman....... .BaV......Chas......Sll.er.......,...............;.....Call for? .............................................................~
Address... _......_.................C.a.e.§y.n.le...... MJ~..r?9.~.r.t.:....:..~.......................... _............................_.. _.. _..~.
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Total
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Amount.~ .........._ ..
Remains to be shipped- see reverse for details.
Interm.nt at....... _........ _.Ro.cky._.Comf.Or..t., ....Mi8.8.0u.l ............................ _........................................... Lot No •..............................._...........Section No ...................................... ;..... Grave No .......... ;................................... . Ramarks ....................... _.. _.......... _.............................................................. _........~............................................................ .
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Lodg.s D Pall Bearers
Information Given To: Relatives D Musicians
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Att.nded To: D Death Certificate D Payment Arranged
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Clergyman Singers
Permit Bill R.nd.r.d
Insurance .......................................................................................... PORM &2..35
8UPERIO~
J'"UNe:RAL SUPPL Y C O R P .. CLEVELAN D , OHIO.
................................................................................... -- ....................
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Date..,Apr.1L.19....._l9.6.Q._ No•......._.._......_.. ____
CHECK EACH ITEM AS
FUNERAL,~RECORi> OF :~',' <' . '. " . Yearly No ...._......_.. _.~.$:?:.:.
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COunty....-Bar.r.y. .. _.........._.. _...Town.hip......._.._.... _... _...........................Phone No............................................ . Wh.r. Born...........,A,r.kansas................................ _.. _.:.._........................... Race..........J1{n1.t.e......................
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\, .... ..Ag•.......................6' Date of BirtIL........6.ell:t.embar....l2.......lIS9.':t 5 ...................................................... (Years) (Months) (Days)
45...
How Long Resid.nt in COmmunity................... x.~~.:r.!L .............................................................................. Singl•................_.......Marrie.r.r..1e.sl.Widowed ....................... Divorced ...................... Child........................... . Husband, Wife or Child oL ..................... B.•....B.•....An.t.la... _...................................... _.................._............... Address..................._............__................ _............~~.~.1;.~r.~.....MJ!?.§.o..~.±......................................................... Closest Relativ•.......UrS.•... O.r.a...P.ur.do.m......................Address ............p.:ur.dY..•....M1s.SQ.ur.L ... Father'. Name......... Ch r 1.s.t.o.ph.e.r....CO.Oper...... _.....Birthplace.......................:........._........................... Mother'. Maiden Name...De1.1a ...M1.c.k........................:.:.,Birthplace... _.. ,............... _..................................... Cau.e of Death ........C.o.r.onary.... Th.r.ombos.1s.........Contritiutory...... Ar.t.ar1.Q.s.c.l.e.r.o.a.1s Dat. of Death......Apr.1l....1.9.•....19.6..Q.............................Hour.............. ~5. .. J)..!.M..,............................. Place of Death......Qa:t.e.9.P.a.1;h.:!.9. ...nQ.!!p...:!.1'..~J .How Long Ill? .................................................... .
.........
!±.;..
Physician.........DI'.•....G.•...H .•....J .OnnS.Oll......................... Addres •.........Qa.!!J?Y.. .:!.JJ~ .......M:!..!!.!!9.\.1,;r1 Occupation of Deceased.,noUael/I.1f.e................................ Social Security No ............................................. . Name of Employer................ __... __ .. __ ...__ ........... _............................................ ~.-......~~-.............................. --.-.. --... ------.. ----Address............................................................................................................................................................................. .
Charge to............ fam1J.y........................................................ ...Address ............................................................:..... .
~:~:ro~~::e:~:::::::·.:~~~~t:=~g~:::J9.:§.Q:::::::::::::::::~.::~i:~s.s::::::;:.:.:::::::::::.?:....~.:;:~(;::.:....:::.:...-:::.-...-.-.-.~.-:. Place of Funeral S.rvice............._...............Exeter._.Chur.ch ....o.f..,.Chris.t....................................... Clergyman......... ..Br.O.•..JJ.llna...Hanc.o.c.k ...:...............Call
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COMP~
Outside
Ca!~~;efault... _.... ~~".:)...........
Embalming Body .................................... Professional Service ............................... . ............ 1 Hair Dresser............................................. . Suit or Dress ........................................... . Shirt, Collar, Tie ...................................... Shoes $......................Hose $...................... Underclothes ........................................... . Door Spray ................................................ Gloves $.................... Chairs $................... . Flower. $.................. Palms $................. . ••.••...•••• 1 Cremation ................................................. . ············1Newspaper Notices ................................. .
I
Telephone and Telegraph ....................... . . .••........ 1 Ambulance
............................................... . ············1 Funeral Coach........................................... . _·········1 Passenger Cars ......................................... . _••••·•• ••••• 1 Pall Bearers' Service ............................... . Transferring Body................................... . Opening of Grave ..................................... . Cemetery Charges ................................... . Lot ............................................................. . Misc. Transportation ................................ Shipping Charges ................................... . Clergyman ............................................... . Singers $................ Organist $................. . Cash Advanced ......................................... . .Bal.e.a ... Tax. ... ·..................................
Total Amount... ............................. . Remains to be shipped- see reverse for details. Information Given To:
Interment at.............Map.l.eyl.o.od ...C.eme.t.e;r.y.. .-........................................................................................... Lot No •............................................ Section No .............................. :.............Grave No .............................................. .
t.".Q...J ....Qh..,....f.~.:L.~ ... .o..r.~.h).,.9: •... J~g.....~.~.g,~ ......
Ramarks ....................#1655....M.Q.o.e.;r.n.ll:!..
....
................................2T6....cedar....n.1ckeJ...,hdw..•.......Lj;... n~.~ p..:r."..g,~),.... ~~.1;JR ........ ........................................WL.lt....o.r.c.b .1.d....C,P.e.::.q!'1....~..~..~n!'1.....1;.r.~.!!L .................. .......................... ....................... ............................... .Maj.9..~._.QAl,.!!k!'1.t..9.g..,....................................... ............................. . ,.ORM 5 2315 SU P ERIOR "UNE RAL SUPPLY COR"., CLKVELAND, OHIO.
o o
Lodges
0 Relatives
Pall Bearers
0 Musicians
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Death Certificate Payment Arranged
Attended To:
o o
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Clergyman Singers
Permit Bill Rendered
Insurance ......................................................................................... .
Date. .......
mr..*J:...gl•...}.2§O
~~
(Boone) FUNERAL
RECORD
CHECK EACH ITE\Il AS COMPLETED
OF' · ' Yearly No................ .:€~.......
Casket ........................................................ $............ :.....
Nam..................................r.ohn... Ruase~l...Ma::l......................................................... Sex. ....... male.........
Outside C.J~~;etault......... (.~".:>. 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 Telegraph ............................................ Ambulance .................................................................... Fun.e ral Coach ............................................... _............. .. Passenger Cars ............................................. _.............. . Pall Bearers' Service ..........................................._....... Transferring Body.................................... .................... Opening of Grave............................... _..... ................... . Cemetery Charges .................................... ................... . Lot ............................................................................ ..... . Misc. Transportation ................................................... . Shipping Charges ............... _... _................................... . Clergyman ................................................................... . Singers $................ Organist $..................................... . Cash Advanced ............................................................. .
No...................._ ..._.__
.......... ....................
Address............................................................................................................................. _.........................................._.. . County................... _.._.._......_.......Township ......._.........................................Phone No ............................ _.............. . Where BOrD............._...•_. __......._...................... _.........._.. _ .... ___...... _............... __ Race......................................_.. _..... .
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Date of Birth. ...................... _...._............ _............................ Age...........•.
_.7.!!:................. _......................................... (Years)
(Months)
(Days)
How Long Resident in Community........................................___ ..................................................................................
Single....................... .Married. ....................... Widowed....................... Divorced...................... Child............................ Husband, Wife or Child of............................................................... _.......................................................................... . Address ....................... _............ _.... _......_........................................................................................................................ . Closest Relative..........................._................................................ .Address.......................................r ••...•.....• . ...•••••.... Father's Name......._.... _.. _.... _............................................ _.. __....Birthplaee... ___ ....................... __............................. . Mother's Maiden Name..._.........._.........__._ ................_................ ..Birthplace... _.........._...__ ........................................ .
Cause of Death............ O.Q.rnll.a.r.Y: ... J.h.r..'?l.!\1?.~.!I............Contributory......................................................... . Date of Death... -Ap.rll...21 •....19.6Q...............................Hour..._..........
.?.:.5..9....:P...~.M.~............................
Place of Death................................................................................How Long III? ..............................................._.... Physician ...........GraC.e ...Wl.;!,l.~.~!!!.!l ..........................:....... Address .............Q.a.§I.§Y..~.))'.~.l ....M.*.f3.flg.ur 1 Occupation of Deceased............................................................. _Social Security No ............................................. . Name of Employer........................................... _._.- .........................................-..:~ .... .-.-~.'................ -................................ . Address ........................................... _................................................................................................................................ . Charge to ....................................................................................... _Address ...................................................................
~:~ro~~::e::z:::::::..AA~ii:::i!t.;::::i.9.:~Q:::::::::::::::::::::. :~:~s.s::.::: ..::;..:::..~:::....:.:::::.:.:.:.......::...:.::...........:....:.........:........ Place of Funeral Service............. _.................. _•.._...... _...............................................................................................
_·_·······1..........................................................................................
Clergyman ......... _.............. _.................. _.........................................Oall for? .............................................................. _
-_······· 1············································ .............................................. _ ··_···1··············································........................ - -
Address..._ .................................... _...................................................... ~;._ ... :........,............. _............................ _.. _.. _.. _.
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Total Amount. ................................. - - - -_
Remains to be shipped-see reverse for details.
Interment at. ......_...................Map~.eYl.Q.Qg,....Q.!il!!!.~.1;.~.r.:Y. ............................................................................... Lot No ............................................. Section No ............................................ Grave No ............................•.................. Ramarks ......................._.. _............................................................................................................................................... .
Information Given To: Relatives Musicians
o
Lodges Pall Bearers
o
Death Certificate Payment Arranged
o
o
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Attended To:
o o o o
Clergyman Singers
Permit BiIl Rendered
Insurance .......................................................................................... FORM !523!1 aUPERIOR F UNER AL SUPPLY CORP •• CLEVELAND, OHIO ;
°7·
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF
-!!!1i..~2 ...
No•......._•._......_ ._ _ _
..............................______________________
____
Name. ......_........_........ .J..e.f.;f.;r..ey. ...Q.l..Jm_..MQr..rJ~ Se:L _____________Ill~:J,~ Address ___________________________ Arular..aQn. __ __ M1s._!'IQ.1J_r.1____________________________________________________ __________________________________ _ COunty___ MCnQnald ____________ Township----.. ----- .. --.----___ ________________________ Phon. No. __________________________________________ _ Where Born..... ____________.J3411~.. -.M1.s.ao.ur.1.------------------______________ Rac. _________!f!t_l.-_~_~
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Casket &
Yearly No ...._.._.._..
(No.) Outside Case or Embalming Body __________ __________ .____ .__________1--------------1-__ _ ------------, Professional Service _____ ___ __ ._____ ________________ 1___ ______ _____1 Hair Suit or Dress ............................................ 1____ _________ -1-.____ _ Shirt, Collar, Tie ...................................... I--------------1 Shoes $________. _____________Hose $ ______________________ 1____ ._________ 1 Underclothes ____________________________________________ 1_________ ·----11-----Door Spray __________________ ______________________________ 1--- ---______ 1.----Gloves $_________ .__________ Chairs $ __ ____ ________ ___ ___1______________ 1 ______
_______________________
Date of Birth.________.Aprn__ 25..._._19.6.Q......_ ... __.__ __Ag._______......________________________ ________________________ __________________ (Y.ars) (Months) (Days) How Long Resident in COmmunity......................................... ___..................................... _.. ___ ...................................... Single__ .. ___ ._. __ ._________ .Marri.d. _______________ ._______ Widow.d _______________________ Divorc.d______________________ Child __ Inf.ant _______ Husband, Wife or Child of......-----------------F-10-y-d---O-len---Mor.r.1s------------------------------------------------------------Address ______________________... _...•_. __..____________________ ..________________Ing,.~.r. .~Qn_. MJ._~_~_ Q~_±
____
____________________________________
________________.Address ________________________.______________,. ________________________ _ MQ_r_r.l!!. __________.___._________Birthplac.______________________________________________ .______________. Moth.r's Maid.n Nam. _____R1J~_ ___'.P.?:_ 9._!!l.P._!!g.!:L_____________.Birthplace~---- _______ ____.__ .............._...... _..____ ._.__ .____ .__ _
Closest Relative_..F.1Q;y.Q....Q _l..M.~n___ M9_r._r.±~ Father's Name __.._F.19.Y..9,___ Q__ ,____
Cause of Death.............._................................................................Contributory. __ ...__ ................................................. . Date of Death____ APrll2~~----~9.6-Q .....---..... -... -.-----------__.Hour______________________________________._... _..________.__.________..._. P lace of Death________S411a __Ho.api:t.al _____.__ ._____ ,, ______ .How Long Ill? ____________ ______________ ____ __ ___ ________________ _
Flowers $_______._ .. _______ Palms $__________________1--------------1.---.Cremation .................................................. 1_________-----1---------- -, Newspaper Notices ............................. _... 1_____________ 1______ Telephone and Tellegrap,h__._____________________ ____________ 1Ambulance ---.__ ._... ______________ _______________________ 1_____ ---------1·----Funeral Coach __ ___ ______ __________ __________ _____________I---· __ .______ 1.-----
I_____________.I______
Passenger Cars .......................................... I____ ......... I ______ Pall Bearers' Service................................ I----.---..---- I-----Transferring ",,'o',do~y-·----- -- --------- --- ------- --------- I ------ ________ 1----.. Opening of c:"T>"',..v.v.., ___________ __________ ____ . ___________ -!-. ____________ 1_____•
Physician........... _........_...._.......................................~..............:...... Address ... :.'................. :.... ::: .. :..................................
Cemetery Lot Misc. '1'r.n o ~. Shipping Charges ______ ______________ ________________ 1_____ ________ 1_____ _
Occupation of Deceased. ............................................ _................ Social-Security No ............................................. . Name of Employer........................................... _... _.........................................: ........._................................................... . Address ....................................................................._....................................................................................................... Charge to ________ E'lQY_Q. ___ MQ_ ;r.;r._l.1L ______________________________________ ...Address ___________ ~_9:~r.:_~g_~l ~~ ~
_____ __ ______________.
Order Given By____ ._____f.}:,!?.Y.:9-____~!?_!:_~_±~ ______________________ ........Address_____________ ________________________________________ ____________ _
21_.__._19.6_Q..........._. _________________Tim._________ :___ ?___ ;p__._M__•________________________________________
Date of FuneraLAp_l ' l l ___
serv1ces
Clergyman __________ __ , Singers $................Organist ,.i._______ _________ __ I--------- ____ Cash Ad.vallce,i ____________···__________________________
11 _ _ _ _ _ _
11 __ _ _ __________ 1 __ • __ •
Place of Funeral Service_____________Emanue~ __ .BIJ.J:l-t.1J?--t.---.Qh1Jr.__<;h~Mg,'__r_!'1_Q_g_,_____ MQ_,_____________. Clergyman______%v._. ___ J-eff-e.r.*a _________ __________._____...___________Call 'n'ount_. ________________________________ I -----I---
To~IA
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__
__ .
Inrermentat ___________.______~~~~:~~~I.~ g~:~;r. g!~~~~~~:~~:
Information Given To: Rela tives Musicians
____ . _____._____ .___________________.______________ _
Lot No •............................................ Section No ............................................ Grave No .............................................. . Ramarks _________________ 2~.._:p~lJ.e. ____Q_1.9_:!;h_~Y.\h_~_~_~ _ ___!'1_~1;Jg____~_~±_J..}. ±~_~~_:r._l.-g_r.:
____
______________ __ __ _
__________________________________________ Hen:::'llal___ Q.a.s_k.!:_t. ___ Q.Q._.________________________________________________________________________________________ _
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o
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Death Certificate Payment Arranged
Attended To:
o
o
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Clergyman Singers
Permit Bill Rendered
Insurance.......................................................................................... ,.ORN 6238 SUPERIOR FUNERAL SUPPLY CORP •• CLBVI!11AND. OHIO .
Date..~:L~J,:~_*_.s.L-1960
CHECK EACH ITEM AS COMPLETF."
FUNERAL RECORD OF No•......._.._......_..__.._ _
Yearly
I
1'IO •••. _ ••••••""""."'U2......._.. .
JJ." ....~n.*-g,~r..........................................................S8%.....III~.~.e..............
N ame. ...•.. _......................_.JUgJ.l!..
Addres •................................._......J.~Ak1!}.!!.•....M*.!-l.!l.c?!:!t:.±............................................................................. COunty.......B.a.rry....... _.._.......Town.hip ....... _.._....•..._...........................Phone No ............................_............... Where Born............. -C.ato.•....Mi.B.B.o.ur.1........._.. _ .... _........_.................Race..........w.b.l.t.e. ......................
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Date of Birth....J.u~..2.4:T...189;3...-................ -....Age........._ .......... (Years)
6.6...... _......... ............................. _....... (Months) (Days)
How Long Resident in COmmnnity......................... l
.".f..@ ....j;_1m~L ...................................................................
Single........................Married. ....................... Widowed ..\V.±g.9..~.~~livorced ......................Child............................
Husband, Wit. or Child of....................E.lla ...s.tO.Q.ktl:m_ ..~ni.!l,.e;rj.D.e.Q.e.ii..!l.e.g,J ...................... Address............. _........_.. _...•_.. _...._...... _.........................................................................................................................
..
Closest R.lative...~yI!\Ql\£i....~l\~~.e..!:: .......................... _.Address ...............~..e..~~~~.~ !.... ~~.~.~.o..'".:
1
Father's N ame.....J.aInaI!LBnlder........................._.._.....Birthplace... _........................................................ . Mother's Maid.n Nam•...Mar.y. ...Mo.or.e..............................Birthplace... _......................................................... Cause of Death............................................................_____ ..............Contributory____ ............................... ___ .. __ .________ ...... . Date of Death ... .Ap.l'l~ ...27........19.6.Q................................Hour...........................
Y:.;.I±.Q...~..,.M.'---..............
Place of Death..Y..•... A
•... HQ.ap.A.F.ay..e.1<[email protected][email protected] Long
Ill? .....................................................
Physician....__ .... ____... __ ...................................................................... Address .................................................................. Occupat ion of Deceased. ....................... f..a*-m.~.r..
................... Social Security
No ............................................ ..
............. 1 Casket ... &....C..•... b.Qx........................... (Style) (No.) Outside Case or Vault............................ .. Embalming Body .................................. .. Professional Service .............................. .. .·.. ····.... 1Hair Dresser............................................ .. Suit or Dress .......................................... .. Shirt, Collar, Tie __ .................................. .. Shoes $...................... Hose $..................... . . ...... , Underclothes .......................................... .. Door Spray ............................................... . Gloves $.................... Chairs $................... . Flowers $.................. Palms $.................. •••••••••... 1 Cremation .................................................. . •... ···.····1 Newspaper Notices ................................ .. Telephone and Telegraph....................... . ............ 1 Ambulance ............................................... . Funeral Coach ..................... ,..................... . Passenger Cars ........................................ .. Pall Bearers' Service.............................. .. Transferring Body.................................. .. Opening of Grave............................... _.... . Cemetery Charges .................................. ..
~~:c.-··T;~~~~·;~·;~~;~~::::::::::::::::::::::::::::::I
Name of Employer........................................................................................................................................................ . Address ........................................... _................................................................................................................................ . Charge to........... .f.aml1y......................................................... _.Address ............................................. _................... . Order Given By.......... faml1y. .................................................Address ................................................................. . Date of Funeral.. ....May.....l
•.....l.9.QQ....................................Time ...........g.:.3..9....i.'.!..¥..~.................................
Place of Funeral Selrvi('e..._..........w!1.."t;O'_.•UJ:u;II.'.,JJJ.._.()I......~i~f:~ILl,......,
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Shipping Charges .................................. .. Clergyman ............................................... . . ........... 1 Singers $................Organist $................. . Cash Advanced ......................................... .
--·······1 .Sale.s....Tax. .......................................
.O'ar.d.a ....o.f... thaok.s..................... Total Amount. ................................. ,
Remains to be shipped-see reverse for details.
Interment at....... _.... Sn1de.t '....C.eP.!.!l.i;..e.r.x ....................................................................................................... Lot No ............................................. Section No ............................................ Grave No ............................................. .. Ramar ks ... _............... C.o.pp.e.l'tone.... .sh.a.d.ed ...p.;r.Q .n?;.~.:::.1!.t.~.P. ...gp.....$.@.+.J............................ .
......................................r.Oil.e.... tan ...Q..r..e.P..~ ....l,[email protected]..*.9..r::p..:t.~±~... .Cl.:v:~:r:.:l.a.,y ........................... ..............................................M~JQt:... .Q.~.E!.~~.~ ... g.~.~.......... _.. _.............................. ............................... ......... FORM 5238 SUPERIOR ,,"UNERAL SUPPLY CORP" CLEVELAND, OHIO.
Information Given To: 0 Relatives 0 Musicians
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Lodges Pall Beal'ers
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Death Certificate Payment A .... _ - _ _ .J
Attended To:
Insurance......
•......................-\
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Clergyman Singers
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51 Date. ....AJlril....
JQ......l9.t:i£L
... . ..... . . ..
CHECK EACH ITEM AS COMPLETED
FUNERAL ' RECORD OF
Casket ...~ ...!?:.Y.,:I,:t:............................... (Style) (No.) Outside Cas. or Vault............................. . Embalming Body ................................... .
fl!I:.:!F.:L...
No........................_ ..__
Yearly No ...................
N ame.......................................Ame.Ua... p..e.mlg:~ ...WhJ...~~ ... l.\.~"'.~..................:...Se%. ...... .f.!l~.;!,!l....
Address..........................................c.aa.ay.ll.le.•.... M1..f).~.Q)J.~1 ....................................................................... County.......Bar.r.~.....................Township ...............F.J~.1;.9.r!l.~.l!; .......Phone No ............................................. Where Born...........Q.aag.e...JJ.o.un.ty..•....M1s.a'OJ..lr..1 ............................Race..........wh.:!..1;.e ...................... .
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!t..................... It... (Days)
Date of Birth.D.e.c.e.mb.e.r..2.6.• ....1.eI.69.................. Age......... _ ...9..Q............................. . . . (Years) (Months)
How Long Resident in COmmunity................:·.~~ ................................................ __ ... ____..........__ .__ ................................ . Single........................Married. ..l'l1i.dQ.\Y. ..... Widowed. ......................Divorced...................... Child ........................... . Husband, Wife or Child of................................................................................: .......................................................... . Address ....................................................................c•••••••••c••••••••.••••••••••••••••••••••••••••••••• c••••••••••.••.•••••••••••••.•••.•••••.•••.••• .•••••• Closest R.lativ•......Mr..s.•...Lor.e.n ...lio.r.n.e.r. ................Address.........Q.al:!.§.y..1;!,.le ...... M~.!'1.l:!9.)J.rl Father's Nam•.........Gua.. P-eJl.C.o.t ....................:.............::...Birthplace..............................................................
Mother's Maiden N ame.......E.!'1.1;.~1..;J,.a ... ;P..~.r.r.*.!1.r. ........ ..Birtlipl~ce............................................................. . Cause of
Death.~~ ... ~.Contributo6:.........................................................
Date of Death......Apr..11...3.Q.,. ....19.6 .................................Hour.................A.•....M.•........................................ Plac. of Death ...........hQme. ..........................:.~ .......:::~::~: ...::....H~w Long III ?.....................................................
..•....S.a..ly!il.~ ......................Address ..... 9.?:.!!.!!.yJ.)..;1,~.......M.~.§.!!.c>.l,lrJ Physician ............... D.r. .•....G.•...W Occupation of Deceased....... P.-.c:>:tl..!l.~I'{.*J.~..........................Social Security No .............................................. Name of Employer............ __. __ .____ ..................... _..._.......................................~.:~~ ......:..................................................... . Address .................................................................................................... :........................................................................ .
Charge to........9.hJ.;!,g.;r.~.r.L ............................................... :.......Address ................................................................... Order Given By..........chi.ld~~D. ......................................... .Address ................................................................. . Date of Funeral... ......Ma;y. ...
J, ....1.9.60.................................Time........:.2..:.P..• ,M ............................................
Place of Funeral Service..........Gul.v.e.r..~.a..J;;he.l2e.l.................,....:........................................................... _.
Clergyman ..........Re:v..•...Q.t.t.O.t:....F.ar.:w.ell...................Call for? ................................................................ Address ................................C.asSy.l11e.•.._Mla.s.Q!.\r1:... ~.....;.....................................................................
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::::::::::::1~~;es~~e::~r~.e~~ic~.:::::::::::::::::::::::::::::::: ........·.·.1 Suit or Dress ............................................ Shirt, Collar, Tie ..................................... . Shoes $...................... Hose $..................... . Underclothes ........................................... . Door Spray ............................................... . Gloves $....................Chairs $................... . Flowers $.................. Palms $.................. Cremation ................................................. . ·..·········1 Newspaper Notices ............................. _... Telephone and Telegraph........................ Ambulance ............................................... . Funeral Coach ........................................... . Passenger Cars ......................................... . _.......... Pall Bearers' Service ............................... . . ........... Transferring Body.................................... Opening of Grave.................................... .. Cemetery Charges ................................... . Lot .............................................................. Misc. Transportation.............................. .. Shipping Charges ................................... . Clergyman ............................................... . Singers $................ Organist $................. . Cash Advanced ........................................ ..
.5als.9. ... Tax ........................................
= :=:::\ :::::::::::::::::::::::::::::::::::::::::::....······················1 Total
Amoun~
,
Remains to be shipped-see reverse for details.
I
Information Given To: 0 R.latives 0 Musicians
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Lodges Pall Bearers
....... .. ...... .........................I~D..".1;.~.....9..z::~.p..i'! ....~~~.:rJg.~:::.().l:'~h.:l..C!, ... y..~:l,y.~.~.....fllll.~;1,;1, ...........
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Death Certificate Payment Arranged
...p.~P.-..~l ..~n.4. ...j;.r .1m..................................................... ..................................................5pr.1ngf.1e.l.d...C.a.!lk.e.~...Mf.K.,....g.2.,...................................................
Insur.a nce..........................................................................................
Interment at. .....................Ho.r.n.er....Ceme.t.ery............................................................................................... Lot No ............................................. Section No.·.............. _............................Grave No .............................................. .
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