CHECK EACH ITEM ,\oS COMPLET
.6.6......_......_...
No•......._ ._......_._ . _ _
Yearly N 0 •. •• _ •. _ ••_ .•
Name. ..._._.................Enl.e.s.t....A.•.. J~;r.Q.c.k ........... _.._.........._.....................................sex. ........Ill§::J,~ ......... Address.............................K§JA.§!?,.!L ..9.J.!;y..,.:..M.t §..~!?1:l.~,1,....................................
. .................................
County ... _.............................._.._...Township....... _........•..._...........................phoii. N 0 •..••••..••.......•...•..••. _ ... ......•.••.. Where Born........Mar!Q......M1.S11.Q.l!.;r.J................. _.._ .... _...........:............... Rac• ..........Y.!J::1.~:!i.~
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......................
.25.•_...1.~a:3.............Age......................25.............................................._.......
n ata of Birth........Q.c.:tQhe.r...
(Y.ars)
(Months)
(Days)
3.... ID.9.nttl.!L............_.................. _...............................................
How Long Re.ident in COmmunity................
Sing l • ........................Marri.d. .. m~;r..rJJ~~idow.d ....................... Divorc.d ...................... Child............................ Hu.band. Wife or Child of....._..........J.e.Q.s.;!.~....\YhJ..?m?JL.! ?.r.Qg.!!:, .................... _.................................. . Addres•............._........ ___...._.._............ _.................. Ki'J.!:H!!?,.§.... g.J.!;.y,.....MJ,!;l.§.().u..~~................................. Clo.est Relative....J--e-e-e.1-e-...B r€Hl-~ ...................................Addr.ss ........................................•......................... Father's Name..........Ir.:v:.1n...Er.Q.c.k. ....................... _.._.....Birthplac•... _......................................................... Moth. r ·s Maiden Nam•....Ma.:r.tha..........................................Birthplac• ... _............................_........................... Caus e of Death.....__........... __ ............. _............................................Contributory___ ..........___ .......................................... Data of Death... _..J.une....4.•....19.5.9...................................Hour .............................. J~.t~:5.
... f.\...,.M.,..........
Place of D.ath...Y..•...A. •... J:!.Q.p..p.J..t.~;L............................. .How Long Ill ? ..............................................._.... Physician .............................................__.....................................__ .... Address .................. _... _........................................... Occupation of Deceased. ...........
fa.r..m.e.:r.. ............. _................Social Security
No ............................................. .
Name of Employer........................................... _... _...................................................................................................... . Address.............................................................................................................................................................................. Charge t o......w.1dWO ................................................................. _.Addr.ss ................................................................... Ord.r Given By ...........wido.w.............................................. _...Address .................................................................. nata of F uneral .......
J_uue ...1.•.....1.95.9.................................Tim• ......................?:..3.9....E'..:.M..~......................
Place of F un. r al S.rvic• ..._.........D.ullT..B.r_!..s....Chap.e.l
Casket ........................ ,... \........................ (Style) (No.) Outside Case or Vault .............................. Embalming Body .................................... ············1Professional Service ............................... . Hair Dresser............................................. . Suit or Dress ........................................... . Shirt, Collar, Tie ..................................... . Shoes ~...................... Hos. $...................... Underclothes ............................................ Door Spray ............................................... . Gloves $.................... Ch.ir. $.................... Flowers $..................P alms $................. . Cremation ................................... _............ . Newspaper N otices ............................. _.. . Telephone and Telegraph. ..................... .. Ambulance ............................................... . Funer al Coach ........................................... . Passenger Cars .......................................... P all Bearers' Service ............................... . Transfe rring Body.................................. .. .. .......... / Opening of Grave...................................... ............ Cemetery Charges ................................... . Lot ............................................................. . Misc. Transportation ............................... . Shipping Charges ................................... . Cler gyman ............................................... . Singers $................ Organist $.................. Cash Advanced ..........................................
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..(l.a l~Jl....T.~........................................
............................................................................._.
Cl.rgyman .... Br.Q.•....K.e.ith... Ma;
[email protected] for? .............................................................._ Addr ess... _......_....C.a.s.s.v..11.le.•....M1..$..(lQ)d.~~...................._._ .......................... _............................ _.. _......_.
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Rem nins to be shipped- see reverse for details.
.l.I.J.J."'",....\J. "jj,' .t>..•,.,".;.,J.......................,..........,............:
Int er ment at...........J:...
Lot No............................................. Section No, .....,.... ,......•..................,.......... G,:ave-'No Ramarks ......................._.. _.............................................................. ,. ... ............~.....-:..~................................................. .
o o
Lodges P all Bearers
o o
Death Certificata Payment Arranged
Musicians Attended To:
OPel Bil:
o
Insurance ................................................................... .. F ORM & 2315 SUPERIOR FUN E RAL SUPPLY CORP., CLEVELAND, OHIO .
Date.. ...
..T.unL!±......J...95.2. ..._
(Boone) FUNERAL ·RECORD ·OF Yearly No•... _.......f.1......... _......_...
No...................._____
CHECK EACH ITEM AS OOMPLEl'ED
...@. Casket ........................................................ $.._ ............. Outside Ca~~t!~e~ault......... ~~~:)........... """""'''' ..... . Embalming Body .................................... ................... .
Name....... _......................_......No.e.l ...J..Q.nft.!l............... _.._.......... _.....................................Sex. .......... ~.
Professional Service .............................................. ..... . Dresser................................................................. . Suit or Dress ............................................ .............. ...... Shirt, Collar, Tie ...................................... .......__ .......... .
·..··· ..····1 Hair
Wh.ere Born.............__ ........ ___...... _.................................. _•._ _.... _........................... Race _______ ....__ .... __ ............................ .
Date of Birth................... _......................_..
(
l:.9..??.............Age.................................................................................. (Years)
(Months)
(Days)
Shoes $...................... Hose $................................. _. ..... . Underclothes ............................................ ................... . Door. Spray ................................................................... .
How Long Re~ident in COmmunity........................................... _..........._................................................................... Single....... _...............MarriedIDarrie.d.Widowed ....................... Divorced ...................... Child ........................... . Husband, Wit~ or CIilld of....._................................................. ,.,'"'. "'~ ...... _... " ....................... _................................... Address....... _...._.._...._.._..._ .._........_.. _...._.................................................................. _.............................................. . Closest Relative._...._.................. _................ _............................ _.Address ........................................, ......................... Father's Name....... _.... _. __.. _.... _.._.............................__ .___.. _.....Birthplac~. _ . ___ .___ ............ __......... _..........__ ........ __ .... .
Gloves $....................Chairs $............................... _....... Flowers $..................Palms $. ............................ _.......
Occupation of Deceased ....__............. __ ...... __ ............... _................ Social Security No ............................................. .
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........................................... _.................................................................................................................................
Mise. Transportation .................................................... Shipping Charges .................................... ................... . Clergyman .................................................................. .. Singers $................ Organist $.................. .................... Cash Advanced ............................................................ ..
Mother's Maiden Name ______.................................... __...................Birthplace. .. _....... __.......__..__ ...........................__ ......
Cause of Death................................. _............................................COntributory............................. _.......................... . Date of Death... _.. _............_......................................................... .Hour........................................................................ Place of Death............................................................................... .How Long Ill? .................................................... . Physician.. __ ............ __... __ .. ___ ................... -...... --......... --..__... -....................A.qQr~$--"~._.'-•._.... __ ... ____ ..._.. _.. _._... _._._ ..........•._...........
Charge to......................................................................................._.Address ............................................. _....................
~::ro~~::e:~:::::::::~i;;~~.:::8.~::::i95.9.:::::::::::::::::::::::~.::~::~ss:.:":...'..............:...~......~...:.~.............:.................:.......................... Place of Funeral Service........... .ao~... c.Qm.f.ar.:t ....e.ap.:tis.:t... Qh.\!,;r..Q!:L ................................... _. Clergyman .........................__ ................ _.........._............................. Call for ? ............................................................. _ Address... _......_............................_...................... _ .._...... _.................._ ...•......................... _............................_......_.._.
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:::::::=:::\ ::::::::::::::::::::::::::::::::::=::::::::::: ::::::::::::::::::
==::::::
Total Amount.................................. I- - - 1
Remains to be shipped-see reverse for details.
Interment at..................RQ.c.kY. ... .Q.Qm.f..Q.r.~.....Q.!?!!!!?.1;.f!.r.:y. ............................................................................ Lot No ............................................. Section No ............................................ Grave No .............................................. . Ramarks ....................... _................................................................................................................................................... .
o
Lodges
D Pall Bearers
o
o
Information Given To: Relatives D Musicians
Death Certificate Payment Arranged
o
Attended To:
o o o o
Clergyman Singers
Pennit BiII Rendered
Insurance .................................................................................__....... FORM 82 315 IIU .. ERIOR FUNERAL SUPPLY CORP •• CLaVEL.AND. OHIO.
Date.······J·Wl.e·· ..9·r ··.l'i/,\i·';l..·-
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF
Ckt --+ ~ as e ....................................................... ..
Yearly No...................6fL .............
No........................ ____
(Style) (No.) I Outside Case or Vault.............................. Embalming Body .................................. .. Professional Service .............................. .. Hair Dresser............................................. .
Name. ............................................l,!/a.1tsJ:.'....!i:-.....stQllJ................................................. sex....!llale............. AddresB ................................................O.I,l.Jl.§.Y..~)..;),~.~.... M~!?.~.():~:;r:.1.-................................................................. COunty.......B.ar.:r.y..................... TownBhip..................f..~.~.9.;r:.e..e..~.... Phon. No ........................................... .. Where Born. ...... P..iak.avl aY. ....C..Q.lJ!J..J;,Y........Qh..l,Q.................................. Race ................... y;J:!.1.-. ~.~ ............. Date of Birth........Sep.t.emb.er....2J.....J..8.S.6....... Age.....................I? ....................................................... (Years) (Months) (Days) How Long Resident in COmmunity............... t.b..r.~l:l ... Y..~.§,r..!?......................................................................... ..
.: ~ ~ : ~ ~ i~ ~:I:~:~ ·~'~: :;.~s:e: :.: : : :~ ~: : : ~: : :1 Door Spray ................................................ ' Gloves $.................... Chairs $.................... 1 Flowers $.................. Palm. $. ................ . Cremation ................................................ .. Newspaper Notices ................................. . Telephone and Telegraph ....................... . Ambulance ............................................... . Funeral Coach ............................................! Passenger Cars .......................................... Pall Bearers' Service ............................... . Transferring Body................................... . Opening of Grave.................................... .. Cemetery Charges ................................... . Lot .............................................................. Mise. Transportation ............................... . Shipping Charges .................................. .. Clergyn1an .............................................. .. Sing!3rs $................ Organist $.................. Cash Advanced ......................................... .
single........................ Marriedmt,r.r.1ed.Widowed....................... Divorced ...................... Child .......................... .. Husband, Wife or Child of..... .f!..l .«'.~.o.J..ey.... S.tahl............................................. ,................................ .. Address ................................._..........................Clil.S..
...
................................Birtbplace...................................: ..........................
Mother's Maiden ~~r ~fl.~ln.e....p~t:f.J.~.!'),J?£!..1,l.Eliltbplace............................................................. . Cause of Death ....d...p.d...e.g.aJ..L£.d.....l:..tl.h...C..L~ ...(. .. _...Contributory._ .............. _... ____ ._____. __ .. _. __ .____ ............. .
9......J9.5.9....................................Hour ........................................................................
Date of Death...... .r.lA!J..e....
Place of Death ..... Q.§.t..e.Ql?§,~hJQ....Hg..(3p...,...................JIow Long III ?.....................................................
Physician ...... Dr. ...... G....... A.., ....p..lJ;r.:v:.e..~................................ Address ............... g.I3.-.~.~.':'.~.:t,~~.I.....1.19. ......... Occupation of Deceased. .... TOllI'i.s.t....O ..o.u.r.:t ....Q.J;l•.e.;r.lfot1idIsecurity No .......
.3.5..:i..::-.:l:.Cl:::.?9..ll4...
Name of Employer .... __________............................. _•.. _...................................................................................................... . Address ................._.......................................................................................................................................................... . Charge to..... '11.idQN....................................................................Address .................................................................. . Order Given By.......... ll!.idow....................................................Address ................................................................ .. Date of Funeral... ...... .T.Wle...12.. ....l959..........................Time ........... ? .. ~..,.M .,........................................... Place of Funeral Service....... C:uJ.~.er..L3 ....Chap.e.l
.......................................................................................
Clergyman ....... Re.y. ......G. .....F.......6.ile.:r.............................Call for? .............................................................. ..
· .. · .. · ...... ........ · · ...... · .......... •.............. · .. .. · .... · .... 1
Address..........................C.a .l!.§y...t.JJ.~.......M J ..i?.(39.1,1.;r:L....................................................................................
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Total Amount......................,
Remains to be shipped-see reverse for details.
Interment at................-Ch1c.ago., .... lllino.1.S. ........................................................................................... .. Lot No .............................................Section No ............................................ Grave No .............................................. . Ramarks ....................... .gl1.a\\;,;f,e.lt ... .c.10.th... Btate....~....ch .......cw.a:r.i1l..awJ
............................
....................... .........wh.l:t.1l.... §.~t~.!).....~.Y!..~.:i..:1: ... :i.l}.~.e..:t'.i..().l:' .......................................................... ..........................................Q.~.l?.tt§,:l:...9.Xt.y.....g.~.~ ~.~.~.....~..()..~............................................................. FORM 511.Sa SUPERIOR FUNERAL .U ....Ly COR .... CLEVELAND, OHIO.
D Lodges D Pall Bearers
Information Given Relatives o Musicians
o
To ~
D Clergyman'
o
Singers
Attended To: D Death Certificate Payment Arranged
o
D Permit D Bill Rendered
Insurance .................................................................. ____ ....................
30 Date. ..... J-une.. ··9,.... l959......_
CHECK EACH ITEM AS COMPLEli
FUNERAL RECORD OF Yearly No ..................6~L
No.................... _ ........_ _
.. _...........
Name. ...... _......................~r.t.r.ude. ..Elac.k. ......................................................... ......Sex. .. f.~.I)).i)J&....... Address ................................. .c.a.65Y.HJ..e.•....M~~l..£!Q]d.rJ .............................................................................. .
F),§:y..<;lY..??..~...............Phon.
COunty......Bar.r.:v:...................... Township ....... Where Born.............Q.;r:9:n?...... M.~~
N 0 ....... ........... ..... ... .. _ ...•..... ......
..~9..~..1.................................................Race ..................~.1.~.~..............
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Date of Birth. ..........A.ugu .
at....l l•.... l2l.ellt-............... Age.............14-............................................................... (Years)
(Months)
(Days)
How Long Resident in Community................................................................................. __ ....................... __ ._....._.. ___ ....
Sing!e........................Married. .......................Widow.d ...YI.ldQy.,.e .aivorced...................... ChUd ............................ Husband, Wife or ChlId of............................J .a m.ss ...F.r.eO".-Sl
a.ck ...........................................................
Address ....................... _.. _................................................................................................................................................. Closeat Relative.........Q.1 J n1;.9..n...l'lJ!l,9.~............................Address ....13.E'.9:."-.:t.~~.I..... I!!.~.~
..~9.1:lE~ .......
Father's Name. ..........Lsaac...Hilt.o.n ..................._.. _.... .Birtbplace..... :....................................................... . Mother's Maiden Name..... S!;l.!l.M ... )J.n!l;ng.l'!.!!..................Birthplace............................................................. . Cause of Death................................. _.................._........................Contributory..__ ........ __ .................. _.............. ___ ........
Date of Death .....J.une ...9.T....19.5.9......................................Hour ........................................................................ Place of Death.... S .e g.a 1 .1
Charge to....~§..1!.i;rt~ ..............................!................................._.Address ................................................................... Order Given By..... ~b.t.1~t:r.e.n .........................................._.. .Address..........................................._.....................
U.L .....b9.5.9.............................Time...................:1.'O'.:..3.'O'....~.:....I\d..~ ..................
Date of Funeral. ....J .JJ.OO.....
Place of Funeral Service............ CUlv.
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D
Remains to be shipped-see reverse for details.
._ ••-. ..7 •
~..
Casket &;. ... ser..v :ic
...
~~~::~:~:~:: I ~~~!t orc~~:;s ;~......................---.-------.--... -
, , e.............._......._______ . ___.. __ _ ............ Shoes $...................... Hose $... _................ . Underclothes ........................ _.......... _.. _.... _ Doer Spr ay .............. __.. _._... _. __ .......... __ .... __ .. Gloves $.................... Chairs $................... . Flowers $..................Palms $................. . Cremation ......................................... __ .. ____. Newspaper Notices ...._......... _._ ..... __ ......... . Telephone and Telegraph ........................ Ambulance ................................................ Funer al Coach ........................................... . Passenger Cars ......................................... . P all Bearers' Service............................... . ............ Transferring Body.................................... ...... _..... Opening of Gr ave..................................... . Cemeter y Charges ................................... . Lot .............................................................. 1 Misc. Transportation ................................ I' Shipping Charges .................................... Clergyman ................................................ Singers $................ Ol'ganist $.................. _.......... Cash Advanced..........................................
s a les tax
~~::.~:~~t~~·~.:~1:J.1~~·~:: : ·: · · :· ·· : : : Total Amount................................. .
••••
Interment at..............D.ak...Hill...C.e me.:t.e ry................................................................................................
D Lodges
Lot No ...._................................. _____ .Section No.__ .................. __ .. ___.. ___ ..... __ .__.Grave Ne ...............................................
D Pall Bearers
....l...ch.............................................................................. .......... . . .......................w.hJ.1i.e .... gQJ.!l .. .
FORM 15 238 S U PERIOR FUNERAL S U PPLY CORP •• CLEVELAND, OHIO.
. ..
o o
Information Given To: o Relatives o Musicians
D D
Attended To: Death Certificate Payment Arranged
D Pee D Bi!
Insurance ................................................................... .
(Boone)
310 CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF Yearly No ...._...... _.ZQ....... _......_...
N 0 ••••...•_ ••_ ...••• ____. _ _
Name. ......_..............._....._..Q.la.:r.!).!1Q.~....NQ.~~!'.L .... _.................................................Sex....l!la.:.~.e.
Casket ........................................................ $.................. (Style) (No.) Outside Case or Vault.................................................. Embalming Body ....................................................... . Professional Service .............................................. ..... . Hair Dresser.................................................................. Suit or Dress ............................................................... . Shirt, Collar, Tie .................................................... ..... . Shoes $...................... Hose $......................................... . Underclothes ............................................ ................... . Door Spray .................................................................... Gloves $.................... Chairs $....................................... . Flowers $..................Palms $................................ ...... Cremation ..................................................... _............... Newspaper Notices ............................. _...................... . Telephone and 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 .......................................... ................... .
..............
Kansa sC i ty, Mis so u ri Address..................................................... _...................................................................................................................... . County......................................._...Township .................•... _........................... Phone No .............................................
Where Born......................._.............._............................ _.. _ ........................__..... __ Race....................................... __ ._____ _
(
Date of Birth............................._............_.......................... ..Age...........•._..5.Q.................................................. _....... (Years) (Months) (Days) How Long Resident in Community.................................. __ ..... __ ................................................................. __ .___ ...... ____ . Singl•........................Married........................ Widowed....................... Divorccd ...................... Child............................ Husband, Wife or Child of............................................................... _...................................... _.................. _............... Address ............._.. _...._.. _...•_.. _............_.................................................................:.: ..................................................... Closest Relative......._...... _............................................................ .Address ................................................................. . Father's Name....... _....__ ._.. ___ ............................................_.. _._ ...Birt~place ______ .. _____ .____............... _.......................... . Mother's Maiden Nama............................................................... .Birthplace... _........................................................ . Cause of Death................................. _............................................COntributory .......................................................... Date of Death... _.......J:une... l
Q•....l9.59...........................Hour........................................................................
Place of Death...............................................................................1Iow Long III ?..................................................... Physician .......................................................................................... Address ................................................................. . Occupation of Deceased......................: ........................................ Social Security No............................................. . Name of Employer ........................................... _..................................................... ~ ............................................. . Address ............................................................................................................................................................................. . Charge to....................................................................................... ...Address ............................................. _................... . Order Given By......................................................................... _.. .Address ................................................................. . Date of Funeral... ......J.une._lJ,.... l9.~9.T .......................Time ....................... ,; ...J'..,.M..,.............................. Place of Funeral Service..._........ _.lln1Qn_.~hur.ch ..................................................................................... _. Clergyman ......... _.............._.................. _.........................................Call for? .............................................................._ Address ..._...................................._...................... _.......................... :..._._•.........................._................................_...... _.
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D
Total Amount............................ ..... - - - , _
Remains to be shipped-see reverse for details.
t e ry Interment at .................Union _........ _........Ceme _............................................................................................................................ . Lot No ............................................. Section No ............................................ Grave No ............................................... Ramarks ......................._................................................................................................................................................... .
Information Given To: Relatives Musicians
o o
Lodges Pall Bearers
o o
Death Certificate Payment Arranged
o o
Attended To:
o o o o
Clergyman Singers
Permit Bill Rendered
Insurance ......................................................................................... . FORM 1S2S!I S U PERIO R FUNERAL SUPPLY CORP., CLEVELAND, OHI O.
311 Date. ......J.une....1.9.~_..1;t5.9_
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF No•......._.......... _. __ .._ _
71
Yearly No • .._.. _.._.. _.................._...
Name. ......_................J.am.e.6.. J;!al.a§9..e.r.;r.y.....Q.J,~y..~D~~.:r................................ SeL ..........~.1..~...... . Addres •......._..........................Qfl,.§.El.yJ],)..~~.....~_~~.~ .().~lC.i.............................................................................. COunty ............. B.a;r.;r.Y....._.......Township ....... _......... ..._...........................Phone No............................................. Where Born.....................T.enn.e.SJHl!:l... ..................... _ .................................Race.............V1h.i..~.~....................
,
.9.•....l .?l.IQ................. Age........................§.9............................................_.......
Date of Birth .......J.anJ.la.r.Y....
(Years)
\
(Months)
(Days )
How Long Resident in Community............................................................................_..................................__ ......._... Single................•.......Married..m ar.r.i e'O'Vidowed....................... Divorced...................... Child........................... . Husband, Wife or Child of...........................)1;Y..~),..Y.IL.?~.~F:i.!I!I?:l:l. ..g:J,.~.y..El.I.1g.El.lC ................................ Addres •............._.._.... _.._..._ .._............ _...............................d.ea eas e.d. ................................................................ Clo.est
Relative._lJ.l~li!lltl.ft...cll..e.llenge.;r........................Addre. s..5J..3....~.,.....P..~y.'O'.!)dli.El.1?l? ... 9..~ t y
Father'. Name._ ..D.a..v:i.d...P.a.i;.:r.;h9.K...9..+..El.Y.~~E~.r..Birthplace................................._........................... Mother's Maiden Name...M~.rgfl,r.El.~...B.CJ.p.~.~.!1.'3. ..........Birthplace... _........................................................ . Cause of Death................__.................................:.............. ~ ............Contributory_._ ... _.....__............................................
l 9•....l 959.................................Hour....... J.9....A.•.... M.,........................................ Place of Death..Bar.r.Y-....C.O.Unty ...B.e.!?:!!... H9.m~ ......lIow Long Ill ?.................................................... . Physician......... D.r. .•...MarY-... Nel!1ma.n................... ,............. Address ........... .Q.(:l,.? .~y:!::l..1..El.•.... M.9...,..........
Date of Death. .._..Iune...
Outside cJ~t;';etault ........(.~~:)............ Embalming Body .......__ ._....__ ....... __. _____ ._._ Pr ofessional Service ........__ .__ .______ ............ Hair Dresser........... ___ ........__ .........__.___ ....... Suit or Dress ........................................... . Shirt, Collar, Tie ...................................... I Shoes $...................... Hose $...................... Under clothes ............................................ Door Spray ................................... _._...._____ _ Gloves $.................... Chairs $.................... ' F lowers $..................Palms $................. . Cremation ._.............. __................................ Newspaper Notices ................................. . Telephone and Telegraph ............... _....... Ambulance ................................................ Funeral Coach ........................................... . Passenger Cars ......................................... . Pall Bearers' Service............................... . ............ Transf erring Body ................................... .
Occupation of Decea sed... __ .f.h\.rme.r......................_................Social Security No .....____ .. __.. __ ..................____ .......
~~~~:::::::: ~:::~:!yofc~::::~:::::~:~::::~~::::~:~:::::::::::::::j
Name of Employer..... ___..................................._.............................................. __ .._......... __............................................. .
Lot ..............................................................
Address .................................. ______ ..__ .________ .. _............. __..... __.............................................. __ ...._....... __.._............................ . Charge to.........T.r.1\m.a n ... QJ&y..~ ;o.g~}:............................. Address .................................................................. Order Given By ....T.];!uman....and ...Sh.e .rman... Q .:),..§.Y~~£ ............... _........................ _.....................
l 9.59.................................Time.....................? ...f .,.M..,.................................
Date of Funera l...June....?.2 •....
Place of Funer al Sernce.......Glio.... G-ema.t.e.r.Y.._........................................................................................... Clergym.n ...... .B.e.11..•.... Melllin ..HenSQn......................Ca11 for? ............................................................._ Addres •......................YIll.e.a:!!.9n. •....M .l§..~.Qg.r.+-..........:........._.............................. _...................................._.._.
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Rema ins to be shipped-see reverse for details.
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Interment at................ Ql.l.Q....C.e.m.e.t .eXy............................................................................................................ Lot No ...... ______ .....___................. __ ... ___Section No............... _... _____.. ___ ....... __ ...... Grave No. ___ .____ .... __.................____ ..___ ......
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312 Date. ...Jl.lIl.e.22,....J.9.53....._
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF No•.......•..•......•..• ..••._ _
Yearly No ..........
.7.2.....................
.emale.... Address.........................................C.a.5.s.Y..l..11e •.....M1!,..(1Q.\P;:J........................................................................ County..........Bat.'.r.;r. .................Township .......•........•...• ........................... Phone No ............................•............... Wher. Born. ............• ........•........•.....Indiana......•.. _ ............................... Race...................wh.l.:t.e..............
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Name.......•...................... l\a%l:tha ...Jane... P.adge.t.t ................................................ Sex.......!
Date of BirtJ::....... S.e;p.temhe.r....~Q•.....l~Zl........Ag........... ...... ~1. (Years)
.. ..........
......................................................... (Months )
(Days )
How Long Resident in COmmunitl"........................................... _.........................................._.___.... _...._......___..............
Single........................Married...lIIXX:r::tJmwidowed.W.;!,.9..g.yf.!?.9 Divorced...................... Child ............................ Husband, Wife or Child of..........................J.ameOl-.. Jl:._... Padg.ett............................................................. Address .............•........•..• ...•• ..•..................................... !j.e.~.eai? l;l.g........................................................................ Closest Re1ative .• ...!l.i£>S-.,....F.lo.y:4....!Mney................... .Address .............. CaaallJ.lli, ....Me.•....... Father's Name........wm....2hLl.maa...Ear.~eyl!l1ne........Birthplace............................................................ . Mother's Maiden Name......PhQ.e.b.e.....S.t.Q.'1!.\'l.r.!L............Birthplace........................................(3 ..J.0.1i....... Cause of
Death.~.i:o../d...,..6?.~AI....Contributory...jfA.A.~k-!!&d.,.....~..... ca...Li.....r.1..:................................... Death ........Sunaet...Vall.ey....Rest ...Ho.mll1ow Long III? .../. .../..1..~. , .................................
Date of Death...•J.\m-e-...22.t..... 195.~ .................................Hour.............. Place of Physician.....D.r._ ...E _... E. •....1 Occupa tion of
cDani.e.l.......................... Address ...........O.a.§J?y.:j),J!?~.....Mu .............. Deceased .........ho.UB.e.wli.e........................ Social Security No ............................................. .
•........... .. .......... __ ..........
Name of Employer..................................__ ......._..._........................................................................................ _............. . Address................. _._ ...................... _...................._... _...................................................................................................... .
Charge to....... Es.tat.e..............................................................Ad.ress ................................................................... Order Given By...... ch.ild:r..en .............................................Address .................................................................. Date of FuneraL. ......•.J.une...24,....~9.5.9........................Time .......................Z....P..•JL............................... Place of F uneral Service.............c.UJ..V.er..!.B•..... Funar.al ..Eo.me...........................................................
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Casket ........................................................ (Style) (No.) I Out side Case or Vault............................. . Embalming Body .................................... 1 Pr ofessional Service .................... __ ......... . Hail' Dresser ...................................... __ ...... Suit or Dress ...__ ...................................... . Shirt, Collar, Tie ........................__ ........... . Shoes $...................... Hose , ...................... 1 Under clothes ....................................... ___.. Door Spray ............................................... . Gloves $.................... Chairs $.................... • Flowers $..................Palms $. ................. Cremation .................................................. Newspaper Notices ............................._... Telephone and Telegraph............... __....... Ambulance ... _......................................... .. F uneral Coach........................................... . Passenger Cars ........................................ .. Pall Bear ers' Service.............................. .. Transferr ing Body ...................__ ............ __ Opening of Grave ............................... __ ... .. Cemetery Char ges................................... . Lot .............................................................. Misc. Transportat ion ......................... __ .... Shipping Char ges .__ .............................. .. Clergyman _.. __ .......................................... . Singers $................ Organist $............... ..
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Clergym.n .. O.• -'l'..•.... Al.r.@Q.,-.c.l¥de ...Mc.C.urm.lc.k.C.n for? ..............................................................• Address................................................................................................ _...........................~~ ........... .
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Lot N o............................................. Section No ............................................Grave No ............................................. ..
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SUPE R IOR FU th RAL SUPPLY CORP .. CLEVELAND, OHIO .
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Ram.rks ..........
Total Amount................ __ ................ , r Information Given To: 0 Relatives 0 Musicians
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Death Certificate Payment Arranged
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Permit Bill Rendered
Insurance.............................. __ ....................................__ ..............__ ....
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(Boone)
Date. ..... J.UJ+e-2.~,.....1~~9_.._
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FUNERAL RECORD OF No........_.._...... _____
Yearly No.... _.. _.._..
_TJ...._...... _._
Name. ...... _..................~e.!l§.!L ...J)..!.. .. Q.?-.;:9:.*P.: ...... _.._................................................. sex.. JllaJ..e. ............ .. Addre..................... _.._............................ _...................................................................................................................... . county.............____ ...__ ._...............__ ..Township....... _........ _... ___.........._____________ ..Phone No. ____ ....................................... .
Where Born........................ _........ _...__ ................ _.......... _.._ ...._........_..... __.:___ . __ .. Race .... ___... __ .. ______ ............................
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Date of Birth ........................................... _.......................... ..Age............. .8.!L ................................................... _....... (Years) (Months) (Days)
How Long' Resident in Community........................................... __ ...................................... ____...................................... Single........................Married ........................ Widowed ....................... Divorced...................... Child ........................... . Husband, Wife or Child of............................................................... _........ _................................................ _.............. . Address ............._............ _...._................ _........................................................................................................................ . Closest R.lativ•._...._........_........ _................................................ .Address ................................................................ _
Father's Name.............._..__................................................ _.. _.... .Birthplace.............................................................. Mother's Maiden Name.................................................................Birthplace....................... _.................................... . Cause of Death...............................................................................Contribu tory......................................................... .
..2S .....J9.59............................Hour .......................~.~}-O ... A •.M......................
Date of Death ..._....... J.un.e..
Place of Death............................................................................... .How Long III? ..................................................... Physician .......................................................................................... Address ................................................................ . Occupation of Deceased. ............................................ _................. Social Security No .............................................. Name of Employer ........................................... _........... _........................._....... _............................................................ . Address_ ..................._........................................................................................... _............................................................. Charge to ................................. _...................................................._Address ................................................................. .. Order Given By......................................................................... _.. .Address ................. _............................................... Date of FuneraL ....... J.une.... 2+.~
....1;l.5.9...........................Time........................?... J)....M.,..............................
Casket ........................................................ $. ............... .. (Style) (No.) Outside Case or Vault................................................. . Embalming Body ........................................................ ······· ·.... 1 Professional Service .................................................... Iiair Dresser................................................................. . Suit or Dress ............................................................... . Shirt, Collar, Tie ......................................................... . Shoes $...................... Hose $... _................................... .. Underclothes ............................................ ................... . Door Spray ................................................................... . Gloves $.................... Chairs $...................................... .. Flowers $.................. Palm. $.................................... .. 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 ........................................................ ..... .
Place of Funeral Servic...........llniQn ...Olll.u:ch._........................................................................................ _. Clergyman ....
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Remains to be shipped-see reverse for details.
e.:r.y................................................................................................ ..
Interment at................ llnlon...Qem.e.t..
Lot No ............................................. Section No ............... _............................ Grave No ............................................... Ramarks ....................... _.. _................................................................................................................................................ .
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Lodges D Pall Bearers
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Information Given To: Relatives o Musicians
Death Certificate D Payment Arranged
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