Date.··-A~.s.t..··l.T .. ··~5-~
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF k t el'..~ " . . .... _ ............................. . Case
No ................~ ...?.."?L... Name.._ .......................E:tta.1io.dg.e.................. :: .........~~ .................................................Sex. .............frunale No..................._ ....._.__
Yearly
Outside cJ~~;e~ault(d)<.~~:).......... .. Embalming Body ................................... . Professional Service ............................... . Hair Dresser............................................. . Suit or Dress ........................................... . Shirt, Collar, Tie ..................................... . Shoes $...................... Hose $.................... ..
Address.................................}:@,1~y.J~.y.{.I.....M.~.!l.~9.~::r'.!..................:::.:.........._......... .................................. COunty.............N.Il.?!.:l!.9..n............Town.hip....... _........ _..._........................... Phone N 0 •.•............. .•.........._ ....... ....... . Where Born. ............ _..__..K.@l?§,.§............... _.......... _.. _ .................................Rac•............... Y[4.1.1;.~.................
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Date of Birth..........E.e.bruao:...5.•....1.S.11...........Age............. _...............8S.............................................. (Years) (Months) (Days) How
Lon~
..:: : : : :: : : : : : : : : : : : : : : :
~:::r~~::;~
Reflident in Community........................................... _.......................... _.........__ .................................... _.... .
Single....................... .Married. .......................Widowed.w1do-we@ ivorced..•................... Child............................ Address ......._.... _...•........ _.._ .._.... _.. _........ _................................................................................................................... Closest ReIative..MrS.•....Sam... MQu.ck........................... _.Address...........Pl.e.r.Q.fl....9.1,ty.•....M.Q.•.... Father's Name. ......Bu.tleI:.. Littl.e...._.............._.._...,.BirthpJ;lce. ................................ _........................... Mother's Maiden Name...l;l.1J.!?an...H9.P.J!;J.n .!? .................. ~irthplace... _.........................................................
Death.C.J,,~~uiw:"'tL.C..fJ
.... . ....... ..................... ........ ....../!? ....~ .... _....
Date of Death. .. _Av.gU.§.ti.... .IYlur..........i".,.~e.~ ~o~.' P lace of Death .....$.)d.!).J!Sl.1;... .Y.@,.:!,J.~.Y. ....RSl.!!.1;... .HQE!.~.Rc:~ l'.~n~iIT .. E'l.~ ~.:
l .......l9.5.9..............................
Physician ........ Dr....... N.o.el... Har.r.i8. ......"......................... Address....P.JJ.r.Q.y:.,. ...Ml.s.8.ouri............. Occupation of D.ceased. .....hQu.s.ew.i.£.6l-........._................ Social Security No ............................................. . Name of Employer ............... __ .......................... _... _...................................................................................................... . Address ..................................................................... _...................................................................................................... . Charge to ............. .e.S.ta.te ...................................................... _.Address ............................................, .................... .. Order Given By........ ],[r.s.....HaD.g.e ............,.........................Address ................................................................ .. Date of F uneral.....AugUS .t. ...} ..... ~95.9............................Time................... 2... :f.3.Q.. .P...•. M......................
.~..r:J4........... .............................
Place of Funeral Service..... .F.airli.lelll.._Bap.t1B.t ....Chur.ch ........................................................_.. _. Clergyman ..... RelT. .. ....C_ ...F. ......Siler...............................Call for ?.............................................................. _ Address... _...... _....Cas.s:l[ille.. ....MtS.S"O.UJ.'.:l.................._ ............................._............................ _...... _.._
(
D
Remains to be shipped-see reverse for details.
Interment at... .....lJR.;l.'OR... .c.em~.tll.x,y.............................................................................................................. .. Lot No ............................................. Section No ............................................Grave No ............................................... Rnmarks .................. ~.oWeJ;!tGn .. ·IHl,r,·f.e~·t.j,Gn.... Slh.r..ine ................................................................ ..
...................................r.es.s ... tan ...Clr..ep.e_.. lnt.e.r.1Q ....."..j ....3....:t.Q ne....p.ane..l............................... .....................................Sp1.'.:lngf.:le.l.d...Cas.ke.:t....Mf./?;.,....Q.9........,.......................................................... FORM 5 2315 S U PERIOR FUNERAL SUPPLY CORP., CLIiVItLANO, OH IO.
I
Gloves $.................... Ch.irs $.................... 1 Flowers $.................. Palms $................ .. Cremation .................................................. Newspaper Notices ................................. . Telephone and Telegraph........................ Ambulance ................................................ Funeral Coach ........................................... . Passenger Cars .......................................... Pall Bearers' Service ............................... . Transferring Body................................... . Opening of Grave ............................... _.... . Cemet ery Charges ................................... . Lot ............................................................. . Misc. Transportation............................... . Shipping Charges ................................... . Clergyman ............................................... . Singers $................ Organist $................. . Cash Advanced ..........................................
Husband, Wife or Child of............................................................... _......................................_.................. _...............
Cause of
-
::',fl,~
-=::=::1 :::·::..·:::::::::::··......···..........·....···....····..······.. I o
Lodges D Pall Bearers
D Death Certificate Payment Arranged
o
o o
D Relatives
o
Musicians
Attended To:
o
o
1
Clergyman Singers
Permit Bill Rendered
Insurance..........................................................................................
Date. ...•...•...•_.A..\1,gg_i?~._.l~_.1.9
59
CHECK EACH ITEM AS COMPLEl'ED
FUNERAL
_tl:."'...._...
No•....... _...•.. _.._.____
Name..- ..•_...................... _.... J.am.e.a ...E.•... .Ant.le... _:............:: ...................................... sex... male .............. Address......._........................_............ E.x.e.t.er.•....M.1.S.S.o.Ur..1. ........................................................................... COunty.............Ba.r..r.:! .._.._.._...Town.hip......._........•... _...............r
... .......
Pb.one No ............................ _...............
Wh.re Born. ...... _...._...._•._........_....!.\~P..~.~Q:l!:.Y...... _.._ .............._................. Race ............~r.~.~.~.f3. ....................
16.,.....11:'l.Tr.......... Ag•.........._........8.1....................z....................l5........
Date of Birth......Dec.ilJllber....
(Years)
(
(Months)
(Days)
How Long ~side"t in COmmunity................. g ...y:eav..s ..................................................................................... Single......._.............. .Married..mar.r.iedWldowed....................... Divorced...................... Cbild........................... . HU'lQand, Wif~ or Child ot.......................... au.s.le....s.t.ey,\~t.;~.... $;\;l.~,.................................................. .. Address ......._...._........_......_ ................_..........................Exete.r......Ml.a.a.Q.u.r.i......................................... .. Clo.est Relative.....Mr.s...._.Sus.1e ...An:tle.................... .Address ....... Ex.et..e.r .......!V1 ~;§.a.9.v..r.J....... Father's N ame. ...... J.ohn...Antle........................................!llrthpla.ce.............................................................. Mother's Maiden/lName....o ....S.J.1,.§!.'\IL.f.f1:~==
..:~.::ijZ~ace..............................................................
...P...M......................
Cause of Death.\.:.~.t4--:::-::rs,.=~ ........contritiutory............~.;.O Date of Death........,A,ugus.:t ... l ..... Hour......................
19.5-9............................
5.,..,)..................,......................
Place of Death.......h.9.m.e............................................................How Long III? .....Il..:z1:1&~ .... ~ Physician· ..........J}p·v ..·a.J.O'll'-€.p .......................................... ·· .. Addres~•.,.. ",M;:t....v..ernQn. ....Mi.aaQuri
'f..;g..~.. .7..':!..r./.
Occupation of Deceased. ........ J'.ar.m.I?.r. ................................. Social Security No .. If:.'1L:-:...
Name of Employer..............___ ._____ .__ ...... ___ ........_... _...... _.............................................__... ____ ......................................... Address ..................................................................... _....................................................................................................... Charge to...........'ILidQYL.e.nd ...
Casket
Yearly No•..._...... _.. .
!:lu..t.l d.r..e.I1.................. _Address..................................................................
Order Given By............w..1.d.o.y1...and....chil.Qr.e.I1....... .Address ................. _............................................. ..
Date of Funeral... ..Dl;iB. ...Ex.e.t.e.;r.... .6.ap..tJ.f:l.~....QJ1.Y,r.q.1j ....,.........
?...;!>..,}!L.................................
(
D
.
Remains to be shipped-see reverse for details.
Interment at ...................~~p~.,w.~G'4... ~. @,~.t€)r.,~............................................................~ Lot No ................................ _...........Section No ................ ............................ Grave No ............................................. .. Ramar ks ................... 6~.;J._.Rus.aet... .B.r.Qnz..e....Sb.'"~.!;!l~....g.9.Pp..~.;t'.................................................... .
...........··........ ·..··..·······R.g.s@ ....l:l-@1g-\l-...¥~,nu.s ...Sar..in"'P..1pe....o.rgan ...Pane.L ........................ .......................................S.P.r..ln(';;f.j,.e.;)..g....Q.i~Jll\:.~_~._.M.!!.g.! .... Q.~.. ~.................................................... ........ FORM 1!128!5 SUPERIOR FUNERA L SUPPLY CORP ••
CLKYI!'L4ND~ . Q ..UO.
~.2- d
.~...~.........................
Outside ca~~t,;;e~ault@..(.~~:).......... .. Embalming Body ... _._ ..................... __ ... __ __ Professional Service ........._______ ............... _ __ ........ __ 1 Ha ir Dresser..... _................... ________ ...... __ .... . Suit oX' Dress .............................. __ . __ . __ ..__ __ Shirt, Collar, Tie .................................... .. Shoes $...................... Hose $.................... .. Underclothes .......................................... __ Door Spray ............................. __ ........... ____ __ Gloves $.................... Chairs $................... . Flowers $__ ................Palms $.................. ......... ___ 1 Cremation .........: ........................................ ' .......... -- Newspaper Notlces .................................. 1 .. ....... __ . Telephone and Telegraph.. __.................. .. Ambulance ....................................... ___ ..... . Funeral Coach ....... _.. __ ......................... __ ... __ Passenger Cars ...................__ ....... __ ........... . Pall Bearel's' Service .............. _... __ .......... .. Transferring Body................ ____ .______ . ____ ... . Opening of Grave....... _............ _.........._.... . Cemetery Charges ................ _____ ___________ .. __ Lot ............................................................. . Misc. Transportation ................ ____ .. __ ...... .. Shipping Charges ......... __ ........ _........ ____ . __ . Clergyman ._ ............................ __ .__ ......... __ .. Singers $.. __ ............ Ol'ganist $___ ... __ ... ____ .__ Cash Advanced ........................ _________ .____ . __ _
~d!.-.<>.l..,~.....................................
Place of Funeral Service......... AllgU.6.t....l-J.."._,.l~......................................................................................... Clergyman ..... .Mc..c.Q.:cm.1.c.k"..E.d.l.e"'.lLan"'.an~.t.......Cal1 fop?
..
--......·1......................................................................
-_..... j ....................................._............................... -<~-lv ~&,.. ·........ ·· ....·....··..· ....l o o
Lodges Pall Bearers
Information Given To: Relatives o Musicians
D Death Certificate o Payment Arranged
o
Attended To:
o o o o
Clergyman Singers
Permit Bill Rendered
Insurance ...... _.. __ .. _.............................. ____ ........... ____ . __ .......__ .__.______.... .
Date. ..A.\!g.1JJ".t.._.~•..
_1.25.9._
CHECK EACH ITEM AS COMPLET.
FUNERAL RECORD 'OF N o•... _.. _._ ...... _..____
Yearly N o.... _.. _..
_&_.lf..s.:::._...
Name..•._._........_....li.end.e.U ...D..ea.n ...l!~.e. ..:....... _.. _.................................................8ex. ..... ~.;L.t? ........... Address ......._........................Ex.e:te.r. •....Mis.sour.1 ...........:.........:................................................................... County.........Ba.:r.r.Y..._......_.. _...Township....),'.1.-J?~.:r_~Y.......................Phone No................·............................ .
............ !
Where Bom............. _Bar.ry....G.ol.Ul:ty:.• _..M ias.Q.u:r.l.......................Race.................:vr.t.J.t .e...............
\
Date of Birth. .....Mg,Y.. ••. :U.~
... J9.5.9..............................Age ....................C? .....................?..................It .............. (Years)
(Months)
(Days)
How Long Resident In Community.......li.f.e ....tillle........................... ~............................................................. 8ingle........................Married........................ Widowed ...................... :Divorc.d." ...................Child....... 9.h.l1d .... Husband, Wife or Child oL ..- ..........-Cur.:t.1s...Lee............. _........_............................ _.................._............... Address....... _.... _........_.. _.._._...._.._.. _............Ex.e.t.e.r.•...JUS..
J:.Q.il,n....r;:{):.~.:r. Mother's Maiden Name... _
............................Birtht>lace... _...................................... _.................
Cause of Death ......UUknO.WIl...natllr.al....Q.alJ.(l.e.l? ..Contributory.......................................................... Date of Death... _.. AlJ~1?:t ....lj..•....
.+.9.5.9. ............................Hour:..................:L....A~.. }~.~................................
P lace of Death ......h.Q.m~ .............................................................How Long Ill? .................................................... . Physician ...........G:r.a.Q.e....lUlU.a.I.l\i? •.....L.!gg§..d-....R.~f!Audres8.......Q.~.~.El.Y..1.-},.:L.t? •....
M.()..,...............
Occupation of Deceased. ___ .... __.__1nfant............................. __ Social Security No ............................................. . Name of Elnployer .. ___...................................... _..._...... _.............................................................................................. . Address .............................................................................................................................................................................. Charge to ...... GU;E'.t .;\,e...Le-e ...................................................Address .......)l;1!;~.!;.!!.r..•.....M~.~.~.9.!!,:r.J........ Order Given By....Mr..•....& ...Mr.S.•....C.ur..t .is ....L.e.e..... .Addre8S ................. _........................ _.................... . Dare ofFU1neral. .......AU~LS:L ... ~. ,' .....~~?~i.........................~~me ...................~~~J.~ . ,M .,c ........ : P lace of l'''uneral Sel7Vi('e.... _........ J!lall!.J...!e.YI'Q.~?g,._~i.e.li!!§J~.ll.;rY. .........................
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Casket& ....S.e.cr.t.9..e..S........................._ (8tyle) (No.) Outside Case or Vault............................. . Embalming Body ................................... . Professional Service ............................... . Hair Dresser............................................. . Suit or Dress ............................................ Shirt, CoHar, Tie ..................................... . Shoes $......................Hose $...................... Underclothes ........................................... . Door Spray ................................................ Gloves $....................Chairs $................... . Flowers $..................Palms $................. . Cremation .................................................. Newspaper Notices ................................. . Telephon. and Telegraph ........................ Ambu1ance ............................................... . Funeral Coach ........................................... . Passenger Cars ......................................... . Pall Bearers' Service............................... . Transferring Body................................... . Opening of Grave..................................... . Cemetery Charges ................................... . Lot ............................................................. . Misc. Transportation ............................... . Shipping Charges .................................... Clergyman ............................................... . Singers $................Organist $................. .
(~:~.,:~~::::::::::::::::::::::::::::::::
=:.:.::=
Clergyman........Re.y..•...Hugh... H1gg.IL ............................Call tor !. ........ .
. .......••••...... •.• •. • •.• • ••..•.•.••• ••••• ••••••• ••• ••.•.....• ...... 1
D
..........
~~;;;;...;;:;;;~~~.~:::::::::::::::::::::::::::::::: ,
Remains to be shipped-see reverse for details.
Interment at..............Mafl.lew.o.oa.. ...C.eme.t.er.y:.............................................................................................
Lot No .............................................Section No ............................................Grave No .............................................. . RamarkG .................. 2J_E>.lLhlue... n.;l._p.ll.e.... I:v.or,y... ..1!lhi.t.e ....s.at1n ...tElill ... int..•.....
p.lain....ah.l.:r.r.
,.ORM 152811 SUPERIOR FUNERAL S U PPL Y CORP ••
CLIIVE~ND;
OH I O . '
o o
o
o
Lodges Pall Bearers
Information Given To: 0 Relatives 0 Musicians At tended To:
Death Certificate Payment Arranged
0 0
o
o
POl BiL
Insurance.................................................................... .
Date. .._.AUgllat ...
5 .._..l9.~
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF .• ~~...
Casket ........................................................ , ..................
Name. ..._._...................... _....Bhorla....I311e....E.r.az.1.e.r........ _..................................... Sex. ........!.emal.e..
Outside ............................... . Embalming Body ....................................................... . Professional Service ................................................... . Hair Dresser................................................................. . Suit or Dress ............................................................... . Shirt, Collar, Tie ............................:............................ . Shoes $......................Hose $.......................................... Underclothes ............................................ .............. ..... . Door Spray ................................................ .............. ..... . Gloves $.................... Ch.irs $...............................•....... Flowers $.................. Palms $.................. ........... _....... Crenletion ..................................................... _.............. . 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 ...................................................... .. Clerg-yman ....................... _..................................... ..... . Singers $................ Organist $......................................
Yearly No.... _.._.._.._..•
No•... _..............__._ _ _
cJ~t;~ault~~~:)
Address ............................................c.!3.§.!?y.l)..l~h... M9...,.................................................................................... COunty..... ~.~!::£Y............__.......Township.......•....¥.:~§l:~.
......... Phone
············1
No .............................................
Whore Born.............Ba:r.o:...!2Q.ldn.!:;y..•.... Ml.§ .§.Q~.~........_................. Race ..............Y!.h.~~.~ .................. Date of Birth..... J.1l.l-1~_.l1-.,.. ..l~.0.6.........................Age············(?~~sT··········(·M~;;th~)"············(Day~)"" How Long Resident in Community........................................ ____............_................. __ ...... __ ............. _........................ . Sing1e. .........._.......... .Marri.d. ...m.ar.r.i.e.dllldowed .................. _... Divorc.d ...................... Child........................... . Husband. Wife or Child of............................ lh.e.o....F.raz.J.e_:r....... _................................................................. Address ....... _.... _........_.. _..__..•...._......•................C.a.a.!l.y.i l l.e .• ....M.l .$.!?Q!J.J;:,l,............................................ Closoot Relativ•._...._.. l!Q.eo....F.J:!azi.e.r. ............................Address .............C.as.all.l~la.,.... Mo..•........ Father's Nam•.......Tb.omaS...J..e.f.f.e.r.aQn ...Ru.a.ae.~lace... _............................ _........................... Mother's Maid.n Name....Nanc.y.....C.a :th.!;l.:r.Jn!;l....~lb~.~;!:
.........................................................
Cause of Death._..._..~ ................................___ ..Contributory ................................................. _....... .
:2•..!l9.5.9.............................Hour ...................2./J!..~A...t:1.l.....................
Date of Death... _..AUilJ.!!J.t ....
:.!..P.....ht.)[.::" ............. _....
Place of Death ............ holll8.................................................... .How Long Ill? ........
P hysici.n .......Dr. ...... G.•...H .•... J .ohns.O.D........................... _Address ......... "".~.Il..§ .!?y.;i,JJ.e.•....M.;I,.§§.9..v.r
i
Occup.tion of Deceased..... hQl.!.s.ew..1.f.e............................Soci.1 Security No ....~.CJ.'f:.::: ..Q.2"..~ ..'{!3.lj il Name of Employer. __ .___ .__ .... ___....... __ ................ __ ....... _........... _...... __................................. ______ ... ____ .... __ ........................... .
Address .............................__... ____.. __ ..... __ .____ .____ ..................................._.............. __.................__ ...... _.. _..... __ .......................... . Charge to.............f .am.LLy. ... & ... I t.l.s.ur.ance................ ...Address .................................................................. . Order Given By....... .F.am.1.ly............................................... _.. .Address ................. _.............................................. . Date of Fun.ral... ...... _...Allgllat....S•.....19.59...................Time ......................2.....p. .•.M................................... Place of Funeral Service... _........ _...c.ul.lr.lil:.!.!? ..•Q.u.a.Q.e..l
......................................................................... _.
Clergyman ........Re.1l..•....D_•....L.,....HQ.1.lll.m'L ...................Call for? ,..........................................................._. Address..........._.............K.anaaS....C.J.ty..•. _.Ml!?.a.Q)).....;l...._..•.......................... _...................................._..•.
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D
=-==1
~~A::~~::::~~r:-=: Totel Amount .................................. I - - - -_
Remains to be shipped-see reverse for details.
I nterment .t................. _..Rus..a.e.l l ... C.e.ni.e..ii.e.ry ............................................................................................ . Lot No ............................................. Section No ............................................ Grave No .............................................. .
R.marks ....................... _...€i/-6-.. lj.oOw.l.O, ....Go1d ...... Go.she.n., ... Lt .• ... RQ.s.e.... Tan .................... .
.... ............ .....................y..~.nU.§ ....!?
D Lodges D Pall Bearers
Information Given To: D Relatives 0 Musicians
D Clergyman
o
Singers
..
(Bo one ) Date............. -Aug.u.s.t-··+T··~5 9
.$.;1.
CHECK EACH ITEM AS COMPLETED
1.
FUNERAL RECORD OF Yearly No .... _...... _........ . .S.2.
No•....... _.._......___ _ _
Casket ........................................................ f............ ...... (Style) (No.) Outside Case or Vault ................................................. . Embalming Body .................................................. ...... Profess ional Service .............................................. .... .. Hair Dresser................................................................ .. Suit or Dress ............................................ .............. .... .. Shirt, Collar. Tie ......................;............................. ...... Shoes $...................... Hos e $.................................... ..... . Underclot hes ............................................ ................... . Door Spr ay ................................................ .................... Gloves $.................... Chairs $.................... .............. ...... Flowers $.................. Palms . $................................ ..... . Cr emation ................................................................ .... .. Newspaper Notices ..................................................... . Telephone and Telegraph............................................ Ambulance .............................................................. ..... . Funer al Coach .......................................................... .... .. Passenger Cars ........................................................ ..... . Pall Bearers' Service .............................................. .... .. Transferring Body....................................................... . Opening of Grave............................... _......................... Cemetery Charges .................................... .................. .. Lot ..................................................................... _........... Mise. Transportation .................................................... Shipping Char ges .................................................. ..... . Cler gyman .............................................................. ...... Singers $................ Or ganist $................................ .... .. Cash Advanced .......................................... .................. ..
N am"-......_....................I.qa..J:.(!:r.mJ.r:!gJ~g.r:! ................_.................................................Sex....tEl.lI,l§:;!,.\ L .... Addr.. s .........................................R.O.ckY. ....Q.Qmt.R.r .:t•.... MJ.§..§.R.Jdr.,j, ...........................................................
COunty..................................._.......Township....... _............ _...........................Phone N 0 ••.........•.. ••...•. ..•. .•. _ ......... .. . . . • Where Bom.. ............ _........ _............ __................ _.......... _.._ .... _........ _............... _.Race........... __ ...____ .... __ .__ . __ ........ __ ...._.
!?.?...............................................................
Date of Birth ........._........_.. _.................._.... _......................Age........._... (Years )
(Months )
(Days)
How Long Resident in Community...................................... __ ... _........................... _...... __ ...._... __ .______ ._____.............. _.... _. Single.............. __ .......Married. .......................Widowed ....................... Divorced ......................Child ............................ Husb.nd, Wife or Child of............................................................... _...................................... _.................................. . Addres •............. _........ _.. _...•_ ......................................................................................................................................... . Closest Rel.tive._...._.................................................................... .Addre.ss .................................................................. Father's Name......................._............................................ _.. _.....Birthplace....................... _..................................... Mother's Maiden Name.................................................................Birthplace............................................................. . Cause of Death...............................................................................Contrlbutory.........................................................:
:7-,.....l95.9...........................Hour........................................................................
Date of Death ... _....AugUB.t ....
Place of Death ...............................................................................1Iow Long III ?..................................................... Physician ..........._............................................................................. Address ................................................................. . Occupation of Deceased. .............................................................. Social Security No ............................................ .. Name of Employer........................................... _... _....................................................................................................... Address ..................................................................... _...................................................................................................... . Charge to ................................. _.................................................... _.Address .................................................................. .
M.r.§!.,....:!';.J:.'.n~.? ~.... ~.?::~.1..~.
Order Given By......... Date of
Place of F uneral Senice. ............ _.... _............ _..._...... _.._........................................................................................ _. Clergyman ......... _...._........__ ................_...._...................................Call for? ............................................................._ Address... _...... _............................ _...._................_ .............................._.._.......................... - ............................_...... _.. _.
D
===:::\::::: :::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::: ==:::::: Total Amount-................................. -
-
- --
Remains to be shipped- see reverse for details.
Interment at............... .9.illT_e.r. ...Qity... D••• IQl&a
..............................................................................................
Lot No ............................................. Seetion No ............................................ Grave No ............................................... Ramarks ......................._.._...._........ _............ _................................................................................................................ ..
o
Lodg es
Information Given To : D Relatives
D Pall Bearers
o o
o
Attended To: De.th Cer t ificate Payment Arranged
o o
Musi ciam~
o o
Clergyman Sing ers
Permit Bill Rendered
Insurance ........................................................................................ .. ,..ORM 15 2315 SUPER I OR FUNERA.1. SUPP1.Y CORP .. C1.EVELAND, OHIO.
...
(bbone)
_ll59
Date. .............,A,uguaL... ."l.•..
FUNERAL RECORD OF Yearly N o.... _.. _.. _...... 81!....._...
No........ _.._.......... __•. _ _
Nam........- ...................... - ......S:t.e.v.e...Ksr.:II'.aIlek...... _.................................................sex.male ................ Addr...................................................WI:l.e.a..t.o.n.,.. .. M.1.aaou.r.i ...:.....:............ _............................................... COunty..........Bar.r.Y........._.. _...Townahip....... _............ _...........................P hone No............................ _............... Where Born.............. __ ...______... __ .._.....__ ..............____...... _.. _.. _ ....__ .........__.. _______ ....... Race................. __ .__ .. _______ ..__ .__ ......... .
6.9.................................................. _.......
Date of Birth..........................................._............................ Age.................. (Years)
(Months)
(Days)
H ow Long Resident in COmmunity........................ __ ..................__ ....... ___ ...________............................... ____ .........__ ........... . Single........•......_...... .Married. ....................... Widowed......._...............Divorce~. __........ _.......... Child ............................ Husband, Wife or Child of................. _............................................ _........................ _............ _.................................. . Address ....... _ ... _...._. ___...•_.._...................................................................................................................................... . Closest Relative....... _.....................................................................Address ......................................,. ....... _................ . Father's Name......•.........._.................................................._.. _.. :..Birlhplace... _.................................. _...................... Mother's Maiden Name........ _........................................................Birthplace............................................................. . Cause of Death .._.. _.._...... _..__ ......_......_............................................Contributory.............................................. _...........
1.•....l9.5.9 .............................Hour ........................................................................
Dat e of Death... _.AUguS.t ...
Place of Death ........................................... _........ _........................ .How Long Ill ?..................................................... Physician ........... _..............._..........................................._..__ ............. Address ...._.................................. _........................ .. Occupation of Deceased.._._ .................. __ ...................................... Social Security No ............................................. . Name of Employer..........................................._...............__................................ ____ .............__ .......... __ ...._....__ ................ . Address ...................._....._........................ __ ..... __.................._................................................__ ...................._.. __ .................... Charge to.......____ ._ ..____ .............. _.. _.............. ____ ....... __ ......... _............. _Address. __ ............................................... __ ............. .. Order Given By................_......................... ____..... ___..................._.. .Address ........................................... _..................... Date of F uneraL ... Aug.us.t ...~Q •....~9.59.......................Time ...........................g.J).,.~~..,.......................... Place of F uneral Service....... __ ...._.... _............_... _...... _.._. __ .. ____ ..............__ .............................. __ ........... __ .................. _. Clerg ylnan ........._....._____........................ _.........................................Call for? ......................................... __ ..................... Address....... __ ..._............................ _............. __ ......._ .. _.......................... _.............................. _........._......... __ ....... _......_.._.
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CHECK EACH ITEM AS COMPLETED
Casket .................~.JL (Style ) (No.) Outside Case or Vault .................... __ ............. __ ......_ ..... . Embalming Body ......................... __ ......... .............. __ .. .. Profess ional Service ................................ ................... . .. ....... __ ., Hair Dresser...... __............................... __ ....................... .. Suit or Dress __ .....__ ................................... .............. .... .. Shirt, Collar, Tie..........._... __ ..................... __ ........... ..... . Shoes $...................... Hose $.......................................... Underclothes __ . __ ....................................... .__ .__ . __ .____ .... .. Door Spray ................... __ ............................................. .. Gloves $....................Chair. $.................................. ...... Flowers $.................. Palms $............................. _...... . Cremation ....................................................._............. .. Newspaper Notices ............................... __ . ____ .......... ..... . Telephone and Telegraph __ ...................... .............. ...... Ambulance ... ____ ............... __ ......... __ .............................. .. Funeral Coach ......... __ ..... __ .......................... ..._.... ____ . __ ... . Passenger Cars __ .............. __ ........................ __ ................ .. PaIl Bearers' Service .............................__ . ................... . Transferring Body............ __...................... .............. ...... Opening of Grave..... __ .......... ____ ... __ ....._..... .................... Cemetery Charges ........................................__ .__ ......... .. Lot ............................................................................ ...... Misc. Trnnsportation.____ ........... __ ............ __ .............. ..... . Shipping Charges .. __ ..... __ ............ __ ........... .............. __ ... . Clergyman .......................................... __ ....... __ ............. .. Singers $... __ ........... Organist $__ ................ ____..... __... .... .. Cash Advanced .......................................... .. __ ...... __ ...... .
.................. ,..................
:::=::=:::\ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
== =:
Total Amount.____ ............................. -
-
- --
Remains to be shipped-see reverse for details.
...................................
Interment at. ...... _......JJ.a.P..;),~:w.Q.QJ't...Q.e!l!.~t.Sl.rY.:::.)g~.t~.r.~....M±.~.~.o..~:r:.j,
Lot No ................................_....... __ .. Section No........................... ____ ..... __ ......Grave No ........... __ ................................ .. Ramarks ...... __ ..............._...................................................... __ ......................... __ .............__ ... __ ....... __ ..........__ .... __ ....____ .. __ ......
Information Given To: o Relatives o Musicians
o o
Lodges Pall Bearers
o o
Death Certifica te Payment Arranged
Attended To:
o Clergyman o
o o
Singers
Permit Bill Rendered
Insurance. __ .................................................................. ___.................. FORM S 238 S U P E RIO R FUNE R A L S UPPLY
COIt~ ..
CL IIVELAN P, OHIO .
(Boone) Date. ............ AlJ..E;1J..!tL.!? ...
J:.2.5 9
CHECK EACH ITEM AS COMPLETED
FUNERAL' RECORD OF Yearly No ...._......_.~..
No•......._.._......_. _ _ __
Ii?:d...B................,._............._
g'1....._...
Casket ..................... (Style) (No.) Outside Case or Vault................................................. . Embalming Body .................................... .............. ..... . Professional Service ....................................................
Nam........ _......................!!innie. ... Le.w.l.!l........... _................... _..................................... Sox.... t.e.male........
Address ............................... B.v.t.te.r.:f.J&;J,..g•....M~§.§lQ1,l.:r:'*- ................ ......................................................... County............................................Township ......._........•................................ Phone No ............................................ . Where Born.. ............ __ ...... ___......._.... _................................ _ ............... _................. Race................................. __ ....... ___ ...
(
...t?9........................................................ . (Months) (Days)
Date of Birth....................... _.................._............................ Ag•.................. . (Years)
How Long Resident in Community.........................................................__ .. _.. _....................... _.................. __ .__ .....__ ..... . Single............. __ ......... Married. ....... ____ ......... Widowed ............ __ ..... ____ Divorced ..... __....... __ ._____ Child........................... . _0"
Husband, Wile or Child of............................................................... _...................................... _.................................. . Address ............._.._........ _...•_.. _............_........................................................................................................................ . Closest Relativ•. _...._........... _........................................................Address ................................................................. . Father's Name......._.... _.._.... _............................................ _.. _.....Birthplace... _........................................................ . Mother's Maiden Name ___._______.______ ....__ ..... __ ....................__........ __..Birthplace.. ____ .__ ..........___ ............... __... _.......__ ........ . Cause of Death. __ ........ __ ...... __............ _............................................Contributory...... __ ......._. __ ....... _.... _............. _............
Date of Death... _........AllgU.at....8. •.....l.9.5.9........................ Hour........................................................................ Place of Death............................................................................... .How Long Ill ?..................................................... Physician __ .................. __ ... __ .......... ____ ................................................. Address ......... __ .. __ ... __ .............. _... _.............. __ .____,___ .. Occupation of Deceased... ________... ____ ........ _................... ____.............. Social Security No ............................................. . Name of Employer........................................... _............................................................................................................ Address ..................................................................... _...................................................................................................... .
Charge to ................................. _.................................................... ...Address ................................................................. .. Order Given By........................................................................._...Address ................. _.............................................. .
Date of Funeral... ...... AugUs.:t ....U ......J9.59....................Time ...............?:).~... J:>..~.~.:..............................
o~r~7::~·::::::::::::::::::::::::::::::::::::::::::::
:::::::::::: \ ::ii; :::::::::::::: :::::: 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 G'r ave .................................................... ..... . Cemetery Charges ........................................................ Lot .................................................................................. Misc. Transportation ................................ .................. .. Shipping Charges ....................................................... . Clergyman .................................................................. .. Singers $................ Organist $...................................... Cash Advanced ............................................................. .
Place of Funeral Service............. _..J?U~Q.;)!_.Eap.t.1S.:t ... Chur.c h .......................................................... _. Clergyman ....Re.v:.~... 'l'.im...Lar.kin.. _...............................Call for? ............................................................._
.............................................................. ······ .. 1- --1
Address..._................. P..UrJiy.•_..M J.§..§9.1J..r~ ........................._.._.......................... _...................................._.._.
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D
Total Amount.................................. - - - __
Remains to be shipped-see reverse for details.
Interment at.............EurJiy....C..eme.t.,e..f.Y.. ............................................................................................... . Lot No ............................................. Section No ...............•............................ Grave No .............................................. . Ramarks ......................._.. _.............._............................................................................................................................... .
D Lodges o Pall Bearers
o o
Information Given To: Relatives Musicians
o o
D Clergyman Singers
o
Attended To: Death Certificate Payment Arranged
D Permit D Bill Rendered
Insurance ............................................................................... __......... FORM 52311 SUPERIOR FU NERAL SUPPLY CORP. , CLEVELAND. OHIO.
-~.$° l
(Boone) Date............. A~\\.§.1;_
..1.?._.l:959
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF
.??.!_...
No........_.._......__._._ _
Yearly NO •......._.. _.......
N ame..•.... _........ _............ _..J..e./;.$.St....P.+..l?fl9IL ..... _......................................................... Sex.......... male ...... .
Kan!?§& ..........................................................................
Addr.. s ................... _....................Hllt.C.h.ln.Iil.Q1).......
COunty......................._...................Township ................._... _........................... Phone No ............................_.............. .
Where Born.................__ ....._............................................_.. _ ...._......................... __ Race.......................................... ___ .. .
(
Cask.t ........................................................ $. ................. (Style) (No.) Outside Case or Vault................................................. . Embalming Body .................................................. ..... . ............ / Professional Service ................................................... .
::::::::::::1 ~: o~~~:~:::::::::::::::::::::::::::::::::::::::::::: ::::::::::::: :::: :
Date of Birt.h................... _......................_............................Ag•........._.. _ lt.lj............................................................... (Years) (Months) (Days)
Shirt, Collar, Tie......................................................... . Shoes $...................... Hose $.......................................... Underclothes ................................................................ Door Spray ................................................ ................... . Gloves $.................... Chairs $........................................ Flowers $..................Palms $.................. .............. ..... . Cremation .................................................. ... _.............. . Newspaper Notices ..................................................... . Telephone and T.legraph............................................ 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 .......................................... .............. ......
How Long Resident in Community.................................................................................. _..................... _.. __ ._. __ . __._. ____ _ Single ........... _........... Marri.d. ....................... Widow.d....................... Divorced ...................... Child ............................ Husband, Wife or (Jhlld of..... _........................................................ _.......__.... ____ .. ___._ ...... ___ .... _........ _........... _.............. . Address............. _........_.._..__..............._.................................................................. _..................................................... Closest R.lative._ ..._ ..•........_........................................................Address ................................................................. . Father's Name..................._.._............................................_.. _.... .Birthplaee....................... _..................................... Mother's Maiden Name........._.................................................... --Birthplace........................................... _................ . Cause of Death........................................................................:......Contributory.......................................................... Date of Death ... _.. _Augu.s.t....
7..,.....1..9.59...........................Hour ........................................................................
Place of Death ....... liJ.l.t.ch.lns.Q.n.•....K.
19.59........................Time.................g..:.3..()... .P... ~.¥..~...........................
Place of Funeral S.rvice..........F.QJL..Q.e!J!.fil.:t~:r.;y.._........................................................................................ _. Clergyman ...... ReV.,....J-GhR-ay:.-lll-LL.l .;l,am-ll-................Call for? ............................................................._ Address..._...... _............................ _......................_ .............................._.............................. _...................................._.._.
D
............................................................... - - - -Total Amount.................................. - - - - -
Remains to be shipped-see reverse for details.
Interment
[email protected]................................................................................................................ Lot No ............................................. Section No ............................................ Grave No ............................................... Ramarks ....................... _....................................................................................................................................................
Information Given To: Relatives Musicians
o o
Lodges Pall Bearers
o o
Death Cer tificate Payment Arranged
o o
Attended To:
o o o o
Clergyman Singers
Permit Bill Rendered
Insurance .......................................................................................... ..ORM :J 23lS SUPERIOR F U NE RAL SUPPL Y CORP •• CLEVELAND, OH IO.
(Boone) Date. ...AUgUat_..ll,.....1;l.59..
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF No•....... _.._...... _..__.._ _
Yearly NO •..._.. _.._.......
.?!._...
Casket ........................................................ ............. ...... (StYle~ (No.) Outside Case or auIt.............................. ................... . Embalming Body .................................................. ..... . Professional Service ................................ .............. .... .. Hair Dresser ................................................................ .. Suit or Dress ............................................................... . Shirt, Collar, Tie .................................................... ...... Shoes $......................Hos e $......................................... . Underclothes ............................................................... . Door Spray .................................................................. .. Gloves $.................... Chairs $....................................... . F lowers $..................Palms $.................. ................... . Crer.{lstion ............................................................,......... 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........................................................ .... ..
Name. ...... _......................_..Char.lfiy.... We.ems. ............. _................................................. S.x............................. . Addr..s ... _.............._.................Fair.:v.:1.ew.•....Mias'O.llr.i.............................................................................. County....................... _................... ToWll8hip ....... _.._.... _... _...........................Phone No ............................ _.............. .
Where
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BOrD.•..•••....•••... ..•.•• _ ................................................ _ •..•.•.•.....•.•...•....•........ Race .. __ ..........______ ........... __ .... _____.... __
Date of Birth.........................._._............_.......................... ..Age..........__._ ............................ _........ _.......................... . (Year,) (Month,) (Days ) How Long Resident in COmmunity..................................__....... _........... _...... __ .. ___... __ ..............................._...._.......... _. Single........................ Married __ ..................... Widowed................... __ .. Divorced ...................... Child........................... . Husband, Wife or Child 01... ....•........................................•.•............ _........_............................_................................... Address......................._.. _.................................................................................................................................................
Closest Relative._...._.._.................................................................Address.....................................~ ....._...................... Father's Name. ............ _...................................................... _.. _.... .Birthplace............................................................. . Mother's Maiden Name.................................................................Birthplace... _......................................................... Cause of Death................................. _............................................Contributory.......................................................... Date of Desth... _.._....................................................................... .Hour ........................................................................ P lace of Death ............................................................................... .How Long Ill? ............................................... _.. _ Physician....... _................................................................................. Address ................................................................. . Occupation of Deceased ............................................_................ Social Security No ............................................ .. Name of Employer ........................................... _........................................................................................................... . Address ..................................................................... _...... _.............................................................................................. . Charge to................................. _.................................................... _Address ...................................................................
~;~~~~-~~-~L~~§~§:~-~~-:~= ~ Address........... _.................................................... _ .............................. _.............................. _........................................ _.
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D
Remains to be
Interment at.....
=::=:::\:::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::
Total Amount.................................. - - - -
s~ipped-see reverse for details.
-:JJ~. . . ._. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . ._. . . . . . . . . . . . . . .. . .. . . . ..
Lot No ............................................. Section No ............................................ Grave No ............................................. .. Ramarks ....................... _.................................................................................................................................................. ..
==::::::
Information Given To: Relatives o Musicians
o o
Lodges Pall Beal'ers
o o
Death Certificate Payment Arranged
o
Attended To:
o o o o
Clergyman Singers
Permit Bill Rendered
Insurance .......................................................................................... FORM 15 2.811 S UPERIOR FUNERA L SUP PLY CORP .. CLEVE LAND, OHIO.
332 Date. .......A.UgullJi....;tQ.~....;!,9.5.9
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF Outside
Address ................................Q.~.l?l?y..*-~~~.I.....~.1.!!.13.?.I!::r:.1. ................................................................................
Embalming Body ................................... . Profess ional Service ............................... .
Wh.re Born.................Kana.aA...................................._ .................................Race ....................I'lh.:.1.~ El.............
..
5..?..................................;...................
Date of Birth .... J.uly....l l..... l.9.Ql......................... .. Age..................... (Years)
(Months)
: : : : : : \ ::i~ o~r~~::~.::::::::::::::::::::::::::::::::::::::::::::
Shirt, Collar, Tie ..................................... 1 Shoes $...................... Hose $.................... .. Underclothes ........................................... . Door Spray ................................................
(Days)
How Long Resident in Community................. _____ ...... __ ..................................................._..................................... __ ....
Single........................Married... ma:r;r..le.~idowed ....................... Divorced...................... Child.......................... .. Husband, Wife or Child oL ........................Ruth... Hu.t.t .On............................................................................ Address...........................................................................C.a.(>.5YJ).J.~.. .... M.~.~ ..1?9};1:r..:t.......................... .. ...... .. Closest Relativ..... Ru.th ...H~.t.:\&n ..................................... .Address ................................................................ .. Father's Name.........K1ID...H.l .lt.t..QJL ....................................Birthplace............................................................. . Mother's Maid.n Name....... NanCY. ... J .ef.f.:rl.e .! L..........Birthplace............................................................ .. Cause of Death ..].[a.S.s.i:v:.e....C.O.r..Qna;r.Y ... 'r.A.:rg.m9..Q(ll,~ibutory........................................................ ..
Date of DeatbAug.U.§t.... .Hour..................... ll.~.50...A.....M. ................ Plac. of Death.....h.ome .............................................................How Long Ill? .................................................... . Pbysician .......Dr.. .... Chas.......R......P.r.19.Sl.........................Address ................c..@,.S..13.1T.~.~.1..El..LJ\~?..~.... ..
J.6......J.9..5.9................................
Occupation of Deceas.d. ... J4Qt.e.l
...QYl.ne.:r...................... Social Security No ........ Jt.9Q....2.!t.J4.1.~ ..
Gloves $.................... Chairs $.................. .. Flowers $.................. Palms $................. ~ Cremation ..................................................1 Newspaper Notices ............................._...1 Telephone and Telegraph....................... . Ambulance ............................................... . Funeral Coach ........................................... . Passenger Cars ......................................... . Pall Bearers' Service................................ ............ Transferring Body... _.............................. . Opening of Gr ave...................................... Cemetery Charges ................................... .
Name of Employer............. __ .. ____ ......................... ___ ...................................................................................................... .
Lot ..............................................................
Address ................. _........................ _........................ _...................................................................................................... .
Misc. Transportation............................... . Shipping Charges .................................... Clergyman ................................................ ............ Singers $................ Organist $................. . Cash Advanced ......................................... .
Charge to...... fuJ,1;h ...Rutt.on ............................................. _.Address ................................................................. .. Order Giv.n By.......Ru.th...Hu.t .t.QXL................................Address ................................................................ . Date of FuneraL .... Av.,g!.+.§.. +..$....... Time ............... g...l.'..
t. ....
;J,9..5.9.......................
,.M.,..................................... ..
Place of Funeral s.rvice........ F.."-r.§t.....!?!)..P...t~~..~...9.h},tf.ifil;sr................................................................ Clergym.n .....Re:\l'.. ....R .....W.......Chane.Y.~.');'fl..11-r.!!!g,n .. Can for? ................................................................
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ca~~tg'~e~ault ...,s}.~~:)............
Name. ............................ O..s.Q.a:r....~..,.... H.1!,~.~gJ.!..........................................:....................sex.male .............. .. COunty..........J\g,IT.Y.................. Township..................................................Phone No.............................................
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c.sk.i&....s.er.:v:.1c.e.iL ...................... ..
Yearly No ......92.............................
No................................ __
D
.....Sal.e.s. ... Tax ................................... . Total Amount................................. .
Remains to be shipped-see reverse for details.
Interm. nt at...........Qak ...H-ill...C.emet.e.r,Y. .................................................................................................. . Lot No ...._....................................... Section No ..............._............................ Grave No .............................................. .
$.j,JyE3.:t:....lJ:J:..El.I1,~.El.
FORM 52315 SUPERIOR FUNERAL SUP,.LY COR" •• CLII:VItLAND . OHIO.
Information Given To:
o o
Lodges
0 Relatives
0
Pa ll Bearers
0 Musicians
0
o o
Death Certificate Payment Arranged
Attend.d To:
OPe Bil
o
333 DateA.Uguat ....1El.,.._.195.9._
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF
Cask.t ..................~...
fI..................... , .................. Outside C,J~t.;~efauIL ..... ~~~:).......................... ..... .
. Y.arly No•... _.._.. _S3_......_......_...
No........ _.._...... _.._____
N ame. ......_...................... _.Le.alie ...Al.le.!l ... Q.a:r.:r. ...............................:....................Sex.........mll.1.c.........
Closest Relativ•. _.. Mr.s.•...Lola....lsl.e¥.........................Address..................................................................
Embalming Body __________ .............................. __ ............. . Professional Service ........... ---......................... _-_.... _.... . .. ___ ._. ___ . Hair Dresser.__ .................... ___.............. __ .... ................... . Suit or Dress .............._............................. ___ ._ ... ___ ." ..... . .._ ...... __ . Shirt, Collar, Tie .................................... _. ............_.. _... . Shoes $......................Hose $......................................... . Underclothes ..... _........ _................................................ . Door Spray _... _......................_.................... _._.............. _.. Gloves $.................... Chairs $............... _... ................... . Flowers $..................Palms $.................. .................... Cremation ............................................. _.... ..____............ .. Newsp.pe, Notices .................................. ....................
.c.ar.:r.............................._.. _.....Birthplace..............................................................
Teiephone .nd T.legraph ........................ .............. ..... .
Address········································Ga·&s'f·l·11e·)·····M.1.s-llG.\.\;v.1 .........................................................................
__· ___ ·· . ... 1
COunty...f!§:!:.r.Y.......................... Township ........... _..... ... _...........................Phon. No ............................ _............... Where Born. .........Q.aJ;l.§.y.U.l~•....Mi§.!?_qY.-.~* .. _....._...........................Race........v~J:lXt..e.
(
........................
..5.•....19..lj..~..................Age.................l,5............................................................
Dat. of Birth.............Ma;r.gh..
(Years)
(Months)
(Days)
How Long Resident in Community..............lif.e....t ..t.ID.e...................................................................................
....
Single..$.J.m~1.e Married. .................,..... Widowed....................... Divorced ...................... Child............................ Husband. Wif. or Child of.•.•. _.....•.•.M:r..s..,....l&;J,.a_ ..;J;.!'!J.~y_ ...................................... _.................. _............... Address ............. _............ _...._............ _.................9.a.~.!?y..~.U·.~ •....M±.§.§g.l!:!:.i._....................................
.......
Father's Nam•....... BJ[.r.Qn..
.. ....... ,..... ~~ ...... : . ... . . .. : ::::::.: Ambulanc.......................................................... ...... Mother's Maid.n Nam•........ Lo.la ... .sml.t h ..........:.............Birth~lace....~... Cauae of Death"~"'~. -ibl Q"b.& ....Contnbutory.. . . . .. . ...."1. . Funeral Coach ............................................ ... - ............. .. A"g t 20 A M -.......... Passenger Cars ............................. _......_................... ..... . 0 Date of Death.....~ U S.. .... Q.,........ . .:;l............................Hour.......................! ...............! ......... !...................... Pall Bearers' Service ____ ............................................. ..
1'"
195
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Pl.ce of De.th......hDme............... (i~;;:;:.:;::; .How Long ¥J? i·····~··~··T······bi Address ..........!.1....y.~.:r:.!! "7.:::....().... ~ ......a , Physician...........D..:r..•..Jt~.n!1 ...........,..Ir'".,.•. Occupation of Deceaaed. ......... sch'O'Q~~.boy.................... _Social Security No..............................................
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Mo·:...···· Transferring
Body........................................................ Opening of Gr.ve............................... _................... .....• Cemetery Ch.rges .................................... ................... .
N.me of Employer........................................... _... _.......................................................................................................
Lot .................................................................................. Misc. Transportation ____ ................... __ ....... .............. ...... Shipping Charges ............. _.... __ .............. _.... ____ . ____ ....... . Clergyman ..............__.. __ ... _...... ______ ... __ . ___________ ............. . Singers $ __ ____ .......... Organist $ ___ .____ .__ ....... _____ _____ .... ...... Cash Advanced ...................................... ___ __.. _.......... .... ..
Address ................. _.............................................................................................................................................___ .. _........ Charge to....... S.t..anda.:r.Q._J,11J.t.1liJ,.;J,....Ag.!?.9.Q........... _.Address ..............c..~f3..~y..:\::!:.1..~.I.
.... ~.~.13.13.c:l.ur 1
Order Given By........Mr..s .•...Ll!.t.h."-:r.....l..!?J,~y..........._...Address ................._........................_..................... Date of Funeral... ..A.lJgl!.S.t. ....;;'.Q~....J9.5.
.9..........................Time......................::? .}'..,.ll!:..,...............................
P lace of Funeral Servic•.........c.\.\.l .\
[email protected]...!.I> •..Qb.ap.e~ .................................................................................. _. Clergyman .....Rev. .•....Lo.:r.en ...Ea-sl.e¥............................Call for? ............................................................._ Address... _.. _.. _...........G.a.'l.S-ll.ille. •.... .Mia.6.Q.u r.i........_.._.._.......................... _............................ _......_.._.
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Remains to be shipped- see reverse f or details.
Interment at................. _........ _..... Mins.ral ....S.P.... 1l:U?;.fL.9..eme.t..e.r.Y. ..................................................... Lot No ............................................. Section No........ _.......... _........................ Grave No .. _................................ _......... ..
l ...<:h.•....s.l1.11'.e.r.... b.l.w~...ma;Q.l ~ ....le."'f............................................... ...... ........... .......... Jy..2.;:y....'!!h.±.~ .~.....i?.!?:_t.J,.!1: ...~.~I.~.~.:t. ....~.~~."..l:'~().~:::?.~1l:~ .. y.~.1..y..~.~.... cl.:.ap e .........................................?.~.n::....Y!:!?-_:J,... 'O'.a.:.fl.~.!':.t....9..()..~..... _.. _.......................................................... ......... I R.marks .................. .D.c.t.•....
POR M tiZ 38 SUPE"IOR "UNI!:RAL S U PP LY COR P. , CI,..V_I-AN D, OHIO .
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Information Given To: o Relatives o Musicians
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Lodges Pall Bearers
o
Death Certificate
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Attended To: Pa.vmFlTlt A""'!>"n""a~
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Clergyman
D Singers
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Permit
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334 CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF No........................ _ ....._ _
Yearly No ............
.9.!:t......................
Name. ................................Lo.tt1.e ....Eliz.ab.e.th...Mahur..in.............................. sJ.5.l.ID.aJ& ......... .. Address ............................................. .iY.?..i2h~g.r.Q:L...M.:),.~.l3g1:!.!:~.................................................................... .. County........ lil-~vr..,il'-...................Town.hip...............ABh..........................Phone No........................................... .. Where Born. ..............Ela,J;!q. ....G.o.u:tn¥., .... Mls.s.aur.i.......................Race............. .I'Ih.it.e...................
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Date of Birth.. lJe-c.euib.e.r. ...ST ....IBSO...................Ag................... (Years)
(Months)
(Days)
How Long Re.ident in Community.......................llf..e ....t .lme......................................................................... . Single ........................ Married. ....................... Widowed.. WJ.g,Qy!..~.~ivorced. ..................... Child .......................... .. Hu.band, Wif. or Child of........................................ .B. .....A ..... Mahur.1n ....................................................... .. Address .............................._
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Closest Relative.... C. ..,....,L.....M?.!1)j.r.J,n............................... .Address ......w.~.s.J.l.!?1:!.~.n.-.L ...~~.Q.................... ..
Father's Name.........He.nr.;¥....l?en9.§r.gr.?..f.1;................Birthplace ............................................................ ..
Mother's Maiden Name....A1:lg.~.1.!!l.~.... l?.~~.El:r:.~..........Birthplace ............................................................. .
Cause of Death..~ ... ~...................Contributory .. ~...'t*w~
9..;.3..Q...:P.....M..,.............................
Date of Death ............. AugUS'\ ....18.......l.9.59 ...................Hour ...............
.5....I)),Q.n.1;h.!? ................ ..
Place of Death...........,ho.me.......................................................How Long Ill? ........
Physician ...D.r. ......Chas.......R.,.....6.r.QW.n ............................ Address.............i?.~.1.!g.Dl.I¥l.,.....IVI~.[l.I3.CJ.u..!'i Occupation of Deeeased ... ___ .hQuawwif.e. ......................... Socia1 Security No ............................................. . Name of Employer..........................................._............................................................................ _.............................. . Address ..........__ ..... _. ____ ... _.. _.. _....................................._..._................................................................................................. ..
...r......MabUr.in...................................Address............ W.aMp..1J.r.n......MQ............... .a milY........................................................Address.................................................................. Date of Funera1... .......Augus.t... 2'O...... ~9.5.9 ...................Tim ......................?.... P....M.................................. Place of Funeral Servic...............Jacke.t. .. S.ch.o.al ..Ho.u.s.e....................................................................
Charge to............ C...... Order Given By....f
Cask.t
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(Style) (No.) Out.ide Case or Vault.................... A...... Embalming Body _................................ _.. Professional Service ............................... . ............ . Hair Dresser..........._................................. . Suit or Dress ....& ...und.e.r.c.lo:th. I Shirt, Collar, Tie .................................... .. Shoes $...................... Hose $.................... .. Underclothes ..... _..................................... . Door Spray ............................................... . Gloves $.................... Chairs $.................. .. Flowers $..................Palms $.................. Cremation ...... _.............. _........................._.. Newspaper Notices ................................. . Telephone and Telegraph ........................ I Ambulance .............................................. .. Funeral Coach ............................................ r Passenger Cars ........................................ .. •........... Pall Bearers' Service ................................ ............ Tran~ferring Body.................................... ............ Opemng of Grave ............................... _... .. Cemetery Charges .................................... I Lot ............................................................ .. Misc. Transportation .............................. .. Shipping Charges .................................. .. Clergyn1an ............................................... . Singers $ ................ Organist $................. . Cash Advanced........................................ ..
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_ ....... Sal.e.s ... T.ax ...........................................
Clergyman .... Re.v. ..... Hom.er....B.ur.n.B................................Call for? ................................................................
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Total Amount................................. . Remains to be shipped-see reverse for details.
Interment at... ............. .Den.t...Qe.me.t.e.nl......................................................................................................... ..
Lot No .... _................................._... _.Section No ................... _........................ Grave No .............................................. . Ramarks ........................#.2.25....6.11y..e:.r. ....M.a9&
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...........................................Silv.e.r....Sa.t.in ....T.VI.ll.l... J .nt..\l.r.;!,.Qr....... .......................................... .. .............................................Spr..1ngf.l.e.l.9. ... g.~.§.~~t. ....M.f.K,.....9.9..,......................... ................. FORM 1I23 !1 SUPERI OR FUNERAL SUPPLY CORP .. CLEVELAND. OHIO.
Information Given To: 0 Relatives 0 Musicians
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Lodges Pall Bearers
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Death Certificate Payment Arranged
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Attended To:
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335
Date......MK'-:\E!~....
:!:?l.,....}:2!2 9
CHECK EACH ITEM AS COMPLETED
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FUNERAL RECORD OF Y.arly No•..._........9.5......... _...... _..•
No•....... _.. _......_. ___..__
Cask.t
Name. ...•__ .................. LQ.t.t ..l~....A.,.....Q.Il.r.p..~.!l\(.~;r.._.......... _..................................... Sex.. J.~mgJ~.........
Fairivew, issouri Address ... _.............. _............ _.................. _...._............M _........ _........................................_.............................................. . County............N.elv.:k9J1...._.......Township....... _.._........ _.................... _.....Phon. N 0 •....•...•...•......•....... _ .. ......••.•.•• Where Born. .....................N.e:Il.t.o.n. ...C.o.JxlinY. •. __~[.J...6.l.l.Q),l.r.;h ............. Race........................l'!.hJ.t.e.........
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Date of Birtb ...... ...I~!?-Y.._.;!,5..I
(Months)
"'.~:~t.~.c.J.Q.!!~::;g"." " 1
Outside C.... or
~ault... ........ _.................
Embalming Body _____ ................... _... __ ..... . .... -....... Professional Service ........ _... __ ................. .
.____ . ______] Hair Dresser........ _______ ....... __ ..........__ ._____ ... . Suit or Dr ess _.........___ ..... __ ....................... .
.....~§.7..§..........................Ag•................~2........................................................... (Years)
II
Shirt, Collar, Tie ___ .........................__ ....... .
(Days)
Shoes $....... _.............Hose $..................... . Underclothes __ ..... ______.__ .................... _...... .
How Long Resident in Community....................ll!!;! ....!!.lm.e............................................................................. Singla........................Marri.d. ....................... Widowed..."!..1.9.-.'?.I'!.E,l.~ ivorced......................Child........................... .
Door Spray ........ __ . __ .__ ................ _... __ .. __ .__ .__ Gloves $.................... Chairs $............... _.. . FI $ p. ,_. • owers .................. >Will> •••••••••••••• ••••• Cremation ................................................. . N.wspaper Notices ............................. _.. . Telephone and Telegraph ........................
Husband, Wife or
Address ............. _....•... _. ____.. _...._................................................................................................................................. Closest Relative._ ..~'tr..§..t ••• J2.:._..~.•J:t~.I.!\!l!Qg!? ..................Address ......1.".'l.!.9:Y..I.....~~.~.(J..El.'?~.r.':I,........... Father's Name.......~.'?.~.§:.El ....~..:....!i.~.~~.El.............. _.._.... .Birthplace.............................................................. Mary Williams .B,·rthplace ............ Ambulance ............................................... . Mother 's Mal·d.n Name ,...·.!--- ··:- · ·· ·· ····n·· · ······ i= ·:····~i ···· · ·· ·T···;-ii:· :;:u,.vt 'b t ... - ...~.:..~.:..: ..~ .~.. ., ......;....;;:.....;::::: ....: •. Funeral Co.ch ........................................... . Cause 0 f Death .~....~... ~::...contrl uory..~.~.~ AU!~JJ.!;1t 18 1959. 2 P M -.......... Passenger Cars .......................................... .
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~:~e..o:f ~:a~~::~::l}g.!!!. ~::.::.:::::::::::..::::::::..:..:..:::::::::::::::::::::::::!::.~~~.~.~~~::.::::~:~::::::::::::' .:::.: : : ::: : : : .::: : ' Dr. F. L. Edwards bxll Monett, Mo.
............. ... . .. ~:~~s~ee:rr~:gS' ~eodrvyice....................................
Occupa tion of Deceased. .............. h.Q1lJ?~.W.J.:f.~................... Social Security No..............................................
Cemetery Char ges ....................................
Name of Elnployer........................................... _............................................................................................................
Lot ............................................................. .
Phys icIan .......................................................................................... Address..................................................................
Address ..............................................................................................................................................................................
Charge to.............C.4.J.l.g;r..e.D................................................._.Address .................................................................. Order Given By...........0.h.:lldr.en...................................._.. .Addr.ss ................._.............................................. . Dats of Funeral... .... A~~.§.~....?.~ :),.9.5..9.......................Time............... ;E'..,.I~., Place of Funeral Servic•............. J1:a.1;r..y.;!.J~Y!....~_I1.p..!;.ti? ~ ....C..h~.r.:g)]....................................................._. Clergyman ........... l}.~.y..:.._.Q..:.... _~.?:.;t.E'i..r.......................... Call for? ................................................................
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.......................................
............................... .
............ Opening of Grave............................... _.... .
Misc. Transportation ............................... . Shipping Char ges .................................. .. Cler gyman ....................... _..................... .. Singers $................ Organist $................. . _ ......... Cash Advanced ......................................... .
__ ....... Sal.e..8....T.ax .........................................
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Total Amount................................ ..
Remains to be shipped-see reverse for details.
Inwrment
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Lodges
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Lot No .......................... _................. Section No............................................ Grave No ...............................................
Ramarks .....................#..6.3.5... Qp9.hJ.g, ....Sh.g,g,~<;l...~.i.},y..~.r.: ...
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Informativn Given To! Relatives Musicians
Death Certificate
.........................................lllQr.y. ... DllChe.S.~L.C.r.ep.e:::-.S.l;x:... .9.;r.Qh.,j,gJ....Y.!?J..Y.!?.!!.. J?Jfl .~ .§.....~n 0 Payment Arr. nged .......................................... 9..~gt.SlJ:....9.J... p..1l:I}.~.~._.~.1..~.. ..P..;!,i3.-.~.~ ....c..r..tJ.p'E,l ....~.~9.-.e~....Il.Il<'l....y..tJ 1vet•.. .
........ .............................t~.l!!....9..I}... p..t~l..'?.'I'....~.cl:...~E~g.!I'::::.?.P..r.:~Il.!??f..:i..e..~.<'l: ... ~.ct.~.1I:e.~........ FORM 1;2315 9UPERIOR FUNERAL SUPPLY COR .... CLItVELAND, OH I O .
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Attended To:
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336 Date.......A~g~§.~ ....?2~
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CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF
Q....................
Yearly No........... ..9..
No.................... _ ..._ . _
C.sk.t ....................................................... . (Style) (No.)
Nam.............................................. lnt.ant....G.iJ!l ...D.ell ...:...:....................................sex........... f.emal.e
Outside Case or Vault............................. .
Addr......................................3J2.S....J..ac.K!!.Q.I1~.... KMJ!g:.!!....QJ.1;.Y~...J'49..-'--...........................~ .............
Emb.lming Body ................................... . Professional Service ................................
COunty............. J .a.ck.eQn .......Township..................................................Phone No ........................................... .
::::::::::::1;~~ o~r;;:::~.::::::::::::::::::::::::::::::::::::::::::::
Where Born...........................Kans.a.s....C.l.ty..•....Ml.s.1l.Q.l.l;r..i ..............Race .........!
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Date of Birth....... Augll.s..t...l9.•....~9.5.9................. Age.........................................................................Th:r. s (Year.) (Months) (Days) How Lon~ Resident in Community.................................................................... ___ .............. __ ................................_.. _.. Singl •........................Married. ....................... Widowed ......................,Divorced ...................... Child ...chll.d ......... Husband. Wit. or Child of........................................F.r..e.ddY. ...D..el~ ................................................................ Address .................~~.8 ~~ K.a!'.Ul.@..!? ... Q.gl~....M~.s. s.g.~.r..~
..........
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................ .....
Flowers $..................P.lms , ................ .
Occupation of Deceased.. ....____ ....................................................... Social Se'c urity No ......... __ ...................................
Cremation ................................................ . Newspaper Notices ............................. _... Telephone and Telegraph....................... . Ambulance .............................................. Funeral Coach ........................................... . Passenger Cars .......................................... ............ Pall Bearers' Service ............................... . . ........... Transferring Body................................... . Opening of Grave ............................... _.... . Cemeter y Charges ................................... .
Name of Employer ..........................................._... _............................................................................. _. __ ... _................. .
Lot ..............................................................
C1o.est R.lati".............. F.X.e.d&....Dell............................ .Address ...................................... Father's Name...............F..r.e.dgy....D.~..lj.............................. .Birthplace............................................................. . Moth.r·s Maiden Name......... NQ.r.ma. ...O.9..Q.P.Sl.!'.'.................Birthplace.............................................................. y •••••.••••• •••••••••••••••
Cause of Death.................. __ ........................................... _..............Contributory.......................................... _...............
Date of Death.............A!lg.Uat....2.Q•.....l9.5.9................... .Hour.................l..A•....M•...~ .....~ ....................... Place of Death.....B.e.sear.ch... Ro..ep.•...K .•.C..•.... MQ.. ,.How Long Ill? ..................................................... Physician ........... _... ________.____............. ___ .......................... __ ......... ___ .__ .Address.................. _....._.................__ ............ _........ .
Address ..................__ .__ . ___.__........ __ . ____ ... _..................._...................................................................................................... .
Charge to........... .F.r.eddy. .. .D.e.l~ ....................................... _.Address ................................................................... Order Given By.................E.r.g.gg;y....p..~}..± .Address ................................................................. . Date of Funeral. ............... AU!l:1\.$..t.....?l~.....J,95.9. .............Time ........................2...) ..·..I~.: Pl.ce of Funeral Service............................. ManQ....Q.eID.~.:Y.~.!'.'.Y.. ....................................................................... Clergyman .......R.e:v...,....W.~.lt..~.!'.'... H.\'
[email protected],.............................Call lor '---..... ...........................:.:::.:....,... .
.........................
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Shirt, Collar, Tie ...................................... Shoes $...................... Hose $..................... . Underclothes ........................................... . Door Spray ............................................... . Gloves $.................... Ch.irs $................... .
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..............................
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Misc. Transportation............................... . Shipping Charges ................................... . Clergyman ............................................... . ............ Singers $................Organist $................. . _.......... Cash Advanced.......................................... ·
_ ........ Sal.e.S....'l'.ax...........................................
Missouri
Total Amount..................................
--- . ~
Remains to be shipped-see reverse for details.
Int.rment at................Mana... lJ.ame.t .e.e.y: ..........~ ................................................................................................ Lot No ............................................. Sec1<{p!!~et...................................... Gr.ve N•............................................... Ramarks ...........................3-.~.... b.lu.e ... .3.l!;;jg:.W; ....~.l!::Y.~.!'.'.;l,9..r.:::Pink ... :v:.e.lve.t .... lnt.e.r..l..Q.r. ..... ······ · ···· ············ ········ ··················~,kl-GG·p4···P.·l,a·stic ....1l-ault...........................................................................
Information Given To:
o o
Lodges
0 Relatives
Pall Bearers
0 Musicians
o o
Death Certificate Payment Arranged
Attended To :
o o
o
o
Clergym.n Singers
Permit Bill Rendered
Insurance .......................................................................................... PORM !!I2S15 SUPERIOR FUNERA L SUPPLY CORP •• C1.EVE1.AND, OHIO.
337
(BOONE) Date.·····A\,\§...s-t ... go)....J.~
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF Yearly No .... _.. _9-1............_......_...
No........_.._...... ______
Name....... _...................... _.....Ne.t.a...Ylorrung:ton. .. _.......... _..................................... sex........female ... Addrees................................._............ VI!1~.aj;_9..n~_ ...M*.~.J?2gr.±...................................................................... COunty............. Jlg.r.r.Y......_.. _...Township....... _.._........ _...........................Phone No .. ,........................._.............. . Where Born. ............ _........ _........ _.. _.............................. _.. _. ___ ._.__ ........................ Race........__ ..................................... .
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Date of Birth............................. _............ _............................ Age ................................................................................ .. (Years) (Months) (Days) How Long Resident in Community............................................................ __......... __ ...._._............................. _..... _........ . Single....................... .Married. ....................... Widowed .......................Divorced...................... Child.......................... .. Husband, Wife or Child of............................................................... _........_............................................................... .. Address ............. _..__......_...._.._...._...................................................c........................................................................... .. Closest Relative._...._........... _................ _.....................................Address ................................................................ .. Father's Name. ..._._ ...._..__.._............................................ _.. _....l!irthplace................................._.......................... . Mother's Maiden Name..................................................................Birthplace.... _. ___.................................................... . Cause of Death............. _.................. _............................................Contributory..·..........................................................
Date of Death ......._AugJJ.s.t .... 2.Q .....L95.9.......................Hour ........................................................................ Place of Death..... G.r.anby.......M.".S.I>Q)J.~.t ..................... .How Long
Ill? .....................................................
Physician .......................................................................................... Address.................................................................. Occupation of Deceased .............................................................. Social Security No ............................................. . Name of Employer..........................................._..._.........................................: ............................................................ . Address ................................................................................ ,........................................................................................... .. Charge to ....................................................................................... _.A..ddress ................................................................... Order Given By..............................................................................Address .............................. ~ .................................. . Date of F uneral. ........_............ _.....................................................Time ........................................................................
JJ~:l.. . . . . . .
Casket ............... $.._............ .. (Style) (No.) Outside Case or Vault................................................. . Embalming Body ...................................................... .. ..·..··....·1Professional Service ................................ .................... .. ..· .. · .... 1 Hair Dresser ................................................................ .. Suit or Dress .............................................................. .. Shirt, Collar, Tie...................................... .................. .. Shoes $....... _............. Hose $...................... .................. .. Und erclothes .......................................................... ..... . Door Spray ................................................ .................. .. Gloves ; .................... Chairs $...................................... .. Flowers $.................. Palms $.................................... .. Cremation ................................... _................ _......... .... .. Newspa.per 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 Service... _........ _.................. _..._...... _.. _........................................................................................... Clergyman ........._.............. _.................._......................................... Ca11 for ?.............................................................._ Address ........... _.. _................................................ _ .........................._.. _..... ~........................ _............................ _......_.._.
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Remains to be shipped-see reverse for details.
Interment at......._........ _........ _........ _............................................................................................................................ .. Lot No ............................................. Section No ............................................ Grave No ............................................. .. Ramarks ........................... _................................................................................................................................................
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Lodges D Pall Bearers
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--
............................................................... _............................ .. ........ FORM e23 8 SUPERIOR FUNERAL SUPP L Y CORP .. CLEVELAND. OHIO.
~
..-............................. .............................................. ~
Information Given To : D Relatives D Musicians
Attended To: Death Certificate Payment Arranged
o o o o
Clergyman Singers
Pennit Bill Rendered
Insurance ..........................................................................................
Date. ..............-Aug.u st
...2.0, ....J.959 . FUNERAL RECORD OF
No........................_ ....._ _
CHECK EACH ITEM AS COMPLETED Yearly No....................
9.I:L ...........
Name.............................. RQ.y: ...C......Elg.1!l........................................................................ sex...male............... Address..............................p.),l.r.:2-.Y.. ,.....~~~..§.~.Y::r.'.~....................................................... ...................................... COunty............BaJ·cr................Townahip..~...............................................Phone No.............................................
Where Born.................. J .fll'l.e.l
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l....Q.Q.l!:\(ny•....KaDJ?Ol..§.......................Race ................. y!.:g. ;l,.~.~...............
Date of Birtb ..Janll.a.I'-¥...1 5.•....1 S.85...................Age................ ll±............................................................ (Years) (Months) (Days)
How Long Resident in Community.......................................................................... __ ......... _........... ___ .......... __ ............. Single........................ Married. ... ~.~.r.:!:A~.~idowed....................... Divorced......................Child........................... . Husband, Wif. or Child of............................I
.da ...E.l..!l:;hD................................................................................... Address..................................................................l.urBy.. ....M.1.s.aQJJ.~,i,............................................................ Closest Relativ.........Rflx •....E1.gin..................................... .Address ... W .a@..+.ng:\(Qn ......IJJJ,l1QJ..S Father's Name... Th QlllaJLQal-.V.01....ElgJn................. .Birthplace......... :.................................................. .. Mother's Mald.n Name....Q.~.l§.!? '!i.;l,<1,... y..@.~.... !!gY.~.*.!'ilirthplace.............................................................. Cause" of Death... __ ... __....______ ............. _............................................Contributory.... __ ............................ ____ .. ___.... _.......... Date of Death.......Augll.s.t .... 2.Q•....1.9.59 .........................Hour ........................................................................ Place of Deatb..... bDme.............................................................How Long
Ill1 .....................................................
Physician .......... D.r._...Ho.well ............................................... Address ...... p..1J.r.g,y.,....Ml.s.SQJJl ·.l Occupa tion of Deceased. .....c.Us.t.odian..".s.ch o.Q.l
.....Social
...........
Security NJJ:9 .9.",Q.7..".7.4:S .1 ......... ..
Name of Employer................................... ___ ..... _..................................................................................... ____ .. __ .............. . Address ........... __ ... __....... __........... __ .............. _._. _____ ...... ___ .. __ ......................... __ ..._...................................._............................. Charge to.........f
.aml .ly..............................................................Address...................................................................
Order Giv.n By....i'amil¥.......................................................Address .................................................................. Date of FuneraL ........Augu.at
...2.4.•....~9.5.9 ...................Time ......................~.. J).,.M...................................
Place of Funeral S.rvic............P..1J.r.Q,y. ....Q-XID....................................................................................................... Clergyman ........... Re.v. .•...,A,l
b l on ...Er.ic.k.s.on ............Call
Address............................~\Q.!'.lg.~ .~., .... Mts.~.o..t;lr.:~
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for 1.............................................................. ..
.............................................................................................
Cask.t &. .. v.ault ....~.. ~ ...................... f (Style) (No.) I Outside Case or Vault.............................. Embalming Body .................................. .. ! Prof essional Service .............................. .. Hair Dresser............................................. . Suit or Dress .......................................... .. Shirt, Collar, Tie ..................................... . Shoes $...................... Hose $.................... .. Underclothes ............................................ Door Spray ................................................ Gloves $.................... Chairs $................... . Flowers $.................. Palms $................ .. Cr emation ................................................ .. Newspaper Notices ................................ .. Telephone and T.legraph........................ Anlbulance .............................................. .. Funeral Coach ........................................... . Passenger Cars ......................................... . ............ Pall Bearer s' Service............................... . ............ Transferring Body .................................. .. Opening of Grave ..................................... . Cemetery Char g es .................................... ! Lot ..............................................................1 Misc. Transportation ............................... . Shipping Charges ................................... . Cler gyman ............................................. .. ............ Singers $................ Organist $.............. .. Cash Advanced ...................................... ..
_......... .B.ale.s. ...T.ax ....................................
_..···....·1 ................................................................. . Total Amount............................. ..
Remains to be shipped-see reverse for details.
C
Information Given To: o Relatives D Musicians
Intermentat............... £ ..~~,.~l .... Y.~~!!~ .'!.s, ~ ...................................................................... ~ Lot No .............................................Section No ............................................ Grave No .............................................. .
....
Ramar ks ...............................lOl1i... A .. .s.il'l.e.~ ...H~w..".:r. ~.f..f..1l,ny.... q9.J,9-.::.!?.~J.y.~r. ~§,9.-.~.g.
.......... ... ..................................6J.U1:t.an....L.+..'Q~;r..1;y. ... .$..~.U!}....~'!. *.!l .,..................................... .. ........ ....................... ................................ C'O.One.r..6.v..U .l .e....Q.MK~.'!i.... Q.Q..! ........ LI,·. 9.:::J.9.~5.6J ................ PORM 15238 SUPER I OR FUNERAL SUPPLY CORP .. CLEVELAND , OHIO.
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Attended To : Dea th Certificate Payment Arr an ged
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339 Date. .. - .....~g.t....l~·r··~9
. ." FUNERAL 'RECORD OF
No............ _...... _.._.. _.._ _
CHECK EACH ITEM AS COMPLETED
Yearly No •..._...... _:;:;..............._.. .
Name......._............... .A.lr.Ila...Gr.ac.s....B.a.xt..e.r.._EmmQJ!.EL..................................... Sex. ......... f.~~.±~. Addr...................................._........ El...Re.na .•....Qkl.p.b.9.illa................................................,.......................... County..............................._.. _.._... Township ....... _................................. ,......Phone No ............................•...............
Where Born._ ..........J.~.ill.s.r...Mi.asQ.1.l.r.i._.._ ..._...........................Race............v,rhl.t .e.....................
66....................................................... . (Months) (Days)
Date of Birth......D.ec.e.mber....27........1551.2........... Age .................... (Year.)
How Long Resident in Community.................................................................... _.............. ___ .... __ ....... __ ........................ Single........................Married. ............. ____...... Widowed ............... ________ Divorced.__................... Child..........................__ Husband, Wife or Child of............................................................... _........................................................................... Addre............... _............_..__.._............ _........................................................................................................................ . Clos..t Relative .........Mr.S...... E.d.VLar.d.. J'.aY......................Address......................................... " ...................... . Father's N am........ J .1.m...Baxt.S.r.................................._.....Birthplace .............................L
................ .............. .
Mother's Maiden Name... _RhaQa ...Ma.r..s.haJ.l
..............Birthplace ............................................................. Death..........nat.ur.a l ...c.alJ.S.e..S........................Contributory...........................................................
(
Outside Case or vault ............................ ... I.. Embalming Body .................................. ...... !...~
....·.·... :.1Professional
Service ················.. ················1············· Hair Dr'.'SElr................................................ 1. ············ .. 1···· Suit or Dr ess ............................................. -1-........... Shirt, Collar, '1'1'.......................................... !..............!.... .. Shoes $......................Hose ~...................... !............... !...... Underclothes Door Spray ..... ............................................. . .. ! ... .......... Gloves $.................... Chairs ~ .................... Flowers $.................. Palms , ................... 1.............. Cremation ...................................................... !............... Newspaper Notices .................................... 1.............. 1...... Telephone and Telegraph ........................ !.............. !...... Ambulance ................................................ 1........······1····..
+....
+........... +....
~:~e ~:a~~:E:i~~:~~:: :t:~i~:~:~;:: : :: : : : : ::::::::~::·~~~;.~;~~:: : : : : : : : :: ::. : :.: : .:::: : :.:: ': : :'
Funeral Coach············································I····.......... 1.... .. Passenger Cars···········.. ···········.. ················I ·······_· .... 1..... . Pall Bearers' Service............................... . Transferring Body................................... .
Physician.... ____..._............................................................................. Address ....................................... :..........................
Opening of Gr a ve··························· .. ·······.. I···········,"'I ......
Occupation of Deceased. .................. h .o.us.e,v.1f.e ............ _SociaI Security No ..............................................
Cemeter y Chaq res ....................................... ! ......... . ... ! .....• Lot ......................................................... ........ -[-........... 1..... .
Cause of o:f
Name of Employer........................................... _........................................................................................................... . Address ........................................... _................................_.............................................................................................. . Charge to....... Ed~Iar.d. ..J~ ... &....O .l .l .g& ...~.Il.;l,.+.J\'l...Address .....A§l!~E.YXl..:t.~.•.... 1<.~.s.~.!3
.....
Order Given By.............a,.bQY.B...................................................Address..................................................................
Date of F unera L.. ...... _.Augu.s.t ....22.~ ....151.5.9. .................Time................
3..;.3..'O'.. )'..,.M..,...........................
Place of Funeral Service......... C.li.Cl ....G.OlIl.lll1lnit.¥....Blao,....................................................................._. Clergyman ......... _.............. _.................._.........................................Call for ?..................................................... Address....... _........................................................_ .........................._~._~.~....~ .... .
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Casket .6C.....t.;..•.... J:j: OJC.,~..................... ..
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Remains to be shipped-see reverse for details.
Interment at................._Gllo....G..e.me.:t.e.ry ................................... Lot No ............................................. Section No ........................................ . Ramarks ................ O.c.t ...
! ...ch.•.... ~Q.t.t.Q.n. ..P.JlJ.@. ... ............ .
: : : : : : : : : : : : : ~~~;~~~~;~:~~~~~~~:~;;:~;~:] FORM !5 23!5 S UPERIOR FUNERAL SUPPLY CORP . , CLEVELAND. OHI O.
········I···········....1......
Misc. Troansportation···· .... ········ .... ···· .. Shipping Charges .................................... !..............!..... . Clergyman .............. .............. ......................-1--.......... .. Singers $................ Organist , ................... Cash Advan.ced ..........................................
I.........,
340 Date. ..........4.ugu6.:t ...2.l ......J..;ZS 9
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD :OF . N 0 ....................... ........._ _
.
Casket O!<]{.a .\J..'.k........ r.:I:., ................. ...., (No.)
Yearly N 0 ..............1.0.0.................
N ame..................................Fr.e.d ... Erank.lin. .. P.ilan.t.......................................:...Sex. .....mal lL........ Addreas .............................................. C.as.s.1l.ille., ....M1.aaQ.ur.L COunty......Bar.....y
............... ~ ...............................................
......................Township ....f.~:!&.r..~.~.f...................Phone No.............................................
Wh.re Born...............Barr.y....C.o.un.tY-.•....Mi a.ao.ur..i ......................Rac•...............w:nJJ& ................. Date of Birth. .....N'O.1l.e.mhe.r.... 2.1.....1.9.Q.6............Age............... .5.2........................................................... (Years) (Months ) (Days) How Long Resident in COmmunity...........................l
i f .e..".time. .....................................................................
Single........................Marri. d.m a r.r..ie.d w idow.d....................... Divorced...................... Child............................ Husband, Wife or Child of... ......................Ev.a...D.iTh.e.ck .. 1?J.lB.nt ........................................................ Address ..............................._ .....................................Q.a.$..$..YJJJ.,..~.•....MJ
.I?§Q)d.r .t ..........:................. ..........
Closest Relative.........tll-idoJN... _................................................ .Address ........................................•......................... F ather's Nam•.......A lb.er..t ....l?.l..l
ant...............................Birthplace ............................................................. . " . ,
Mother's Maiden Name...........Mar.y....I'O'lIl.e.........................Birthplace.............................................................. Caus. of Death......br..o.ucU.O....);lne.lAffiQ.n Jfl..................Contributory .......................................................... Date of Death.AUg U S.:t....2.1•.... J.959...............................Hour................3..:.3.Q. ..1?.•.M.•............................
1.-....mQIJ..~.h ....................
Place of Death.... F.r .e.e.ma.n."J.Q;Q.l;\.n......MQ..................How Long III ?...........
+............. +........... +...........+.....
1.. .. . Embalming Body ..................................... ............. Prof essional Service ................................. 1.. ... . ............ , Hair Dr ess" ................................................... 11. . . . . ... . . . ... . 1 . . . . .. Suit or Dress ................................... ............. Shirt, Collar, '1'1,• ••....•••.••••••••• •.•••...•..•...•...... 1.............. . Shoes $...................... Hose ~....................... I...............I...... Underclothes ............................................ 1••••.••• •• •• •• Door Spray ................................................ 1••..........•• Gloves $.................... Chairs , ................... Flowers $..................Palms $.. ................ 1.............. 1.... . .............. 1 Cr emation ········............................................ 1.·· .. ·········· 1····.·· Newspaper N otices .................................. 1.............. 1..... . Telephone and Telegraph ........................ I...•.......... I...... Ambulance ................................................ 1.....·········1······ Funeral Coach··· .. ·······································I·····........1...... Passenger Cars··········································I····.· ........ 1...... Pall Bear ers' Service ................................ I..............I......
+........... +....
Transferring Body···································· I·············.1 ...... Opening of Grave······································ I·········· .... 1•••••• Cemetery vharl:es······· ·······························I ·······....... Lot ................................ ............................... 1....•. Misc. Tr.m:po:rt a tiolo...................................j. .............-1-.... Shipping Char g es .................................... 1.............. 1.....• Clergyman ................................................ 1.....·········1······
...E. •....lip..sh.e.r............................ Address ....................J\;I?Il.!?I?.(l ....9.J:1;y..•....M.o • Deceased. .. O.Wn.er.:;".AJ.l.1&...P..
Physician ............AJ.her.t Occupation of
+. ...... . .
Name of E mployer ........................................... _............................................................................................................ Address .............................................................................................................................................................................. Charge to .............
YrJ9:9..v.:...!¥l.9:....1.p..I3.'l..:t:.~'? .~ ..............Address..................................................................
Order Given By............r.§,!II.:t.~y. ..............................................A ddress.................................................................. Date of F uneral. .......A ugu.s.t ....
1' . . . .••
2.J•....19.5.9.....................Time .............G..:.3.9.. J'..•.M.., ...............................
ll.e.:c.!..a ... Chap.el.................................:....................................................... Clergyman ..... O~.!J)..•.... A.l .v.e-G_Ro.y....l/I.j.J.liam.sOn.Call f or ?..............................................................._
P lace of Funeral S.rvic.......CUl
I
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..·..··..···1 ....................................................................." Total Arooulllt.................................. :
Remains t o be shipped- see reverse f or details.
Interment at ................. .Pilan.t....G.eme.:te.ry.:............................................................................................... .
Lot No •............................................ Section No.......... :.................................Grave No .............................................. .
o
Lodges D P all Beal'ers
....9.n.;......lo. ....•••.•••..•.•••...•. ••. 0 .......................................l..?;;;.3..J.&.. p.J.lA.~...•Q.r.~p.~ ....9:~.....Sl~.~.f.l.~.... ~.:~~.~9:IOtJ:l....v!..~.~.... l:).e..n.:~er 1 .........................................r.ay.....~!1..J·.7.?1..,...... p..r.....!.J.1.:ll.~ ...'?E....~!:!: ...IOtJ:l.'l.....s..~.'l.f:l ....I'.il{.... ~.F2. g ir
I nfor mation Given To: Relativ.s D Musicians
Ramarks ...................2}Qi:"'.s.lJ·.9} .. r.ub:o.e.d ...g:w:une .ta.l....b..l..8.ml.J
.... . ................ ...........Q.Qnn....r.!l.y..+..~..;!..1.-....g.§,~~.~.~.....Q.o...:................................... ..... ..................... . FO R M 5 23 8 S U PER I O R ,.UNERA L S UPP LY COR P .. CLE V ELAND , O HI O.
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Attended To: Death Certificate
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Clergyman Singers
n Permit
Date.-.M.g=t._2.2T··..l9.~S-
FUNERAL
CHECK EACH ITEM AS COMPLETED
RECORD OF . Yearly No ............ ~l ..................
No..........._............_ ..._ _
....... _.... 1Casket -· ..·· .. ···· ··· .. ·· .. ···················· .. ···· .. ··· ..
·····I~,...........--1-.-...
(No.)
Name.........._... _........................ J.ame.B. ...E.d\2a.:r..d ._.S.l.ll ..1.1y.aIl...........__ .... _... ____ ...___ ..Sex.........!!!~.l!L ... _..
Outside Case or Embalming Body Address_._._.... _...._...................... _.. _.... __... __ Ell.r.dY..•.. Ji!i.S_S.Q_lJ•.:r..i._.__ .._.. __ ._ ............ _.. _____________ .__ ..............__...._.__ ._.. Professional Service ..................... _........... 1.....• _....... 1 COunty-___ .l;l.a.J;!r.1f._ .. _..................Township._ .................c............................ __ Phone No. ___________._______ ._._. ___ .............._.. .......... _. 1Hair Where Born...... ______Barn... QQ.un.t J:......JY1;Ls .,sQll.:r.J ...... ::........_..... _..__ Rac........ ___ ....y!.hJ.t.~......... __ ........ Suit or Dress ............................................. -I..... Shirt, Collar. ;·············· ....··· .... ········ .... ·.._····1_··_·_····_·.. 1 Date of Birth. .... F..e.br.\l.Sl.r.;y: ... ~6......11:l5..1 .......... .. Ag•. ______............... l!$......... _. __._ ... __ .. _......................... _" __ " (Years) (Months) (Days) Shoes $...................... Hose .~ ....................... I.......... __.I Underclothes ............................................ 1.........·····1 How Long Resident in Community........................................ ____.. ~ .................................... __ ...................................... . Door Sp" ay .............................._..........._..... 1.............. 1..... . Singl............ _........... .Married....maJ:·r.1.~ .
-+...-........
(
+ ............+ . . ...
_.195.9.............................
Occupation of Deceased. __ .____ .farmar. ................................... Social Security No....5.QQ:-::J.2.:-::Q3.6.3. .....
Dateof Fullen.L_........~~,~y~." ... ,;2J,.... ,b2.:2 2.................... :Timle .. "; ............. ~2" ... JP c.,. :J~~ ,· ....................................
Cemetery Charges···································· I···· ......... 1.... .. Lot .............................................................. 1............. -1.... .. Misc. Transporta t ion ................................ I.... ........ _.I ...... Shipping Charges .................................... 1._....... ···1····.. Clergyman ....................... _....................... 1......·······-1·· .... Singers $................Ol'ganist ; .................. 1.............. 1...... Cash Advanced ................................ .......... :..........._.. 1.. ... .
Place of Funeral Selm('e...__ .......J"-Q;[Hl;~r:~.~YL..@.~..1~f!!?g,~~!..~....~'.I.' .I~::',!I::l..................:
................. -........................... .. .........···..···11 ····-_·_....·+....
Clergyman ....... .B.g"'._.....li'r.g,nci.S ... Car.r..........................Ca11 Ior '! ........ _._ ........... _
--.......................................................·············1········-1-·....
Name of Employer ......................................................................................................................................................... Address ............................................................................................................................................................................. .
Charge to.. _... _.__ .. lII.i dw.o..... _................. _......................................Address ...... _.... _.. __.................................................. . O"der Given By...... _....YL~.9._g~'!........_......._.................................. .Address ................................................................. .
\
D R~mains
to be shipped-see reverse
Total
~or details.
Interment at.................Longlli .e.\!t... G.eme..t .e ry .............................................................................................
A·nnolm~ ..............................~"
Information Given To: 0 Relatives D Musicians
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Lodges Pall Bearer s
.................................. r.o .s a ....tan ... .s.a:tin ...t.w.ill ....;In:t.e .r. ;i,Q.r..~.~p.:r..?,yS!9.... hg'lV..,................. ..
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Death Certificate Payment Arranged
.................. _........._._._..... __..S.Qr..inf;f.i.e.l 9.-....O....ll11&:!<... Mf13..:.... Q.9...:.......... _...........................................
Insurance..........................................................................................
Lot No ................................ _........... Section No ......................................-...... Grave -No............................................... Ramarks ...............~~O!-§....G;pl:JG.~@ ....sl;J,&d{t.d... c 'O.PiJ ...r..t'O'lle .... s:ta.el ...~... c h /. ........................
FORM (l2SZI SUPERIOR FUNERAL SUPPLY CORP •• CLEVELAND. OHIO .
Attended To:
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Clergyman Singers
D Permit Bill Rendered
o
Date...Augl.l.S.t_.2.8. •.....l9~
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF Yearly No.... _...... _.;!,Q.?...._..... _...
No........_.._...... ___
Nama....__........ _............ _.... Edg~ ...G.•....MQr gan ...._.......... _..................................... Sex..: .......mal..e ........ Addres•................................._.........C.as.s.Y..1l.1e.•.... MJ..$.!?Q.\!r..~.................................................................... . COunty... B.aITY. ........ _......_.. _... Township......._............ _...........................Phone No ............................................. Where Born. ............II~.e.ay.J.nSl.•....M.1.~.!?.Qm:.J,............. _................. Race ..................... .'!Y.l:}..j,.t..~...........
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1I ,....J:9..9.lJ:........Ag•.................... 2~........................................................
Date of Birth. .........NQ.y..ii'.mp..I).r ....
(Years)
(Months)
(Days)
How Long Re.ident in COmmunity...........n1ne....montha............................................................................. . Single........................Married..mar.J:'ia.d Widowed .......................Divorced...................... Child............................ Hu.band, Wife or Child of......................... Emma. ...MQrgan._ .............., ......................._................................... Addre.s ......._...._........_.. _.. __ .. _...............................Ca.s.av.ill.e. •.... Mo..•........................................................... Closest Relativ•....... ..Emma... Qr.ge.n ................................ .Address ........................................•......................... Father'. Name..........J".ohn...H.e n r.;r. ...M9.;rgal1..............Birthplace................................. _........................... Mother's Maiden Name ...~.~F.@ ....~.:... g.;.!? s.'O'.~ .Birthplace..._.........................................................
__ _
•• _ •
• ••• _ •• _
Opening of Cemetel'Y
Name of Employer ___.___ .................................... _........................................................................................................... .
Lot Misc. T,
Address ............................................_.. _.. __ ... _............................................_......... _......... _...... _.................................... _........ .
Cash
Place of Funeral Service............ G....J,"'-9-P.!-8-.-Chap.e.l ..............................................................................._. Clergymnn...Re:'l.•... ~Qnd...alaQ.k...........................Call for? ............................................................._ Addres"..................C.e..$..s.Y.;l.l.1.e .•....M1~..€l_9.1J.:r.~.............._.._._ ........................................................_......_.._.
N.l:...f3.p..~ .'?.~§::J,......................................
............. ..........RQ.s.~.t.a.n..Ji;mp..r.@.§J,... _Q.r.@p..~... Jg.t...,....
............... ....................~P..!.:.~n.g~~~_~.9:....Q.~.s.~.~.~_..~t~:....g9. . ~.................... .... ..................... ............ FORM l!I .2.8l!1 SUPIZRIOR FUNERA L SUPPLY CORP •• CLEVE L AND, O H I O.
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Total Am
Remains to be shipped- see reverse for details.
Ramark•........ ·· ....·.#2-2-0 ... S11'l
......
Shipping Charges Clergyman Singers $............._..Organi st
Charge to....... Emm&-.. J!or.gan ...............................................Address .................................................................. . Order Given By..... Elnma ...MOJ:'gan ................................... .Addre.s ......, ...................................._..................... Date of FuneraL ..... AugUs.:t.... 31.•....1959.....................Time ............................ )~....A.,.....M.,..................
Lot No ............................................. Section No .............. __ ......... :.................. Grave No .................. _........................... .
......
Passenger ('!!! Pall Bearers' ~, Transferring Bod'
•••••••• _ ••••••
Interment at.........G:antr.y_.. Al?karul.a .6 ............................•...............................................................................
~
Funeral Coach.
Occupation of Deceased. ......:t:a .I'.ffi@r. ..................................... Social Security No ..........~~3.:::'.<:l.1.=.3..5..§.§.
D
(No.)
Cr emation Newspaper Notices Telt:: phone and A mbulance
f ........................... •
cJ~t,;;efault.
Gloves $....................Chairs $. Flowers $..................Palms J
Date of Death... _... AU§:u-S-.t ... 2g,. ... l~\}9....................... .Hour................, .:.} O...A. •....M•........................ Place of Death.l/. .•...-A..•... HQSp.ital.".E'.ay.e.tt.e:'l.il11~ Long Ill? ..................... • • • ____ • • __ • • • • • • •
Outside
······ 1 ············I
Cause of Death ...... C.o.iijlapse._.o.f ... lung. ....................Contrlbutory..........................................................
o_ • • • • _ _ _
- Va u l t - sa l e.§.l'ctJC
Embalming Body P rofessional Service H ajr ......_..... Suit or Dr ess Shirt, Collar, Tie. Shoes $...................... Hose Underclothes Door Spray
.............
Physician .... ___ .....................__............................................................ Address ........
Casket
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Inform ,
Lodges
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D Pall Bearers
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,--
Attended To:
Death Certificate
1:> ______ .1-
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,/
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-
.
o• Singers
Musicians
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-
..-...
Permit
Date. ...A.~~J; ....
Z.9..s.....1922-
FUNERAL
CHECK EACH ITEM AS OOMPLETED
RECORD of' . Yearly No •......} .Q3........................
Cask.t ..&.... fil.er..v.ltl..e.s....................... !
Name............................................J .e.s .s... J.Qhn.. ,X.e.e~lng.......................................... Sex. .............I.!!?,;),sL.
Outside Ca~:~;·~ault ...... (.~~:).. .@... . Embalming Body .................................... . ............ i Professional Service ................................
No................................_ _
Address........................................... .P.ur.dy.·r .. ·.1lis.s.o .ur.1. ................................................................................ . County.......Bar..r..Y...__.._.._.._...Township..............~±~§l~.~.Y................Phone No............................................ .
: : : :: : \~:i~ o~r~::e~::::::::::::::::::::::::::::::::::::::::::::
Where Born...................... B.a.r.r.Y. ....Q.Q.1UJ..U~....M1..~.~Q.h!r.),................Race...................\\1!J,.j,.i;.~............ ..
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Date of Birth. ......J.lJn!L.~......1~.~.9
............................ Age..................7..C>........................................................... .
(Years)
(Months)
I
(Days)
How Long Resident in Community.................................................................... __..... _..................... ___ .. ___ .................... Single........................Marri.d .. marr.1.e.Owidowed....................... Divorc.d...................... Child.......................... .. Husband, Wife or Child ot..........................Le.Qra .. J.QD.e... ,X.e.e .l 1ng.................................................... .. Addres ............................ _._._ ..................................... ;P..~gy...... M),.\?..\?.Qh!r..~ ................................................ . Closest Relative.........Le.u~a ..J .Qn.e.s....K.e .e l .1ng. ...... .Address ................................................................ .. Father's Name....... J'..a.a..s-.. .M~....K.iJ.e.l Mother's Maiden
.1.ng....................ilirthplac.....:......................................................... Nam.......Al:ln ...Ji!C!m ..................;..............Birthplace............................................................ ..
Cause of Death ...~.~ .Contributory.. ~......... ..
M.t.................................
Date of D.ath.........Aug.ust... .2~.,.....1959........................H~ur.............0.....lL ..
............ ............
Plac. of Death....... hom.e........................................................... .How Long Ill ? .................................................... . Physician ............Dr.......NQ.e .l ...E..... H a r..r.l.s.................... Address ................. :P..l1.r.g,y......M.;1..§..~QWrJ. Occupation of Dec.as.d. ..........Far.mer. ................................. Social Security No ............................................. . Name of Employer.................................. ___ . __ ... _............. _............................................................................................. .
Address ..................................................................... _....................................................................................................... Charge t o.............. Ji'maj,.l,y................:........................................Address ............................................. _.................. .. Order Given By................... F.amily. ........................................Addr.ss................................................................ .. Date of F un.ral... .........s.e.p.t.e .mb..er .... l ......l9.5.9............Tim............. :................~.. .J)..'..M .,.........................
............ _.......... _.........
Plac. of Funeral Service..........Y.?~g.y..~~!....9.~~~
.........................:......................................................... _.
Clergyman ........................._...........................................................:.Gall· for? .............................................................. _
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D
I
Shirt, Collar, Tie...................................... Shoes $......................Hose $.................... .. U nd~rclothes .......................................... .. Door Spray ................................................ · Gloves $.................... Chairs $.................. .. Flow.rs $.................. 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 .................................. . Clerg yman ............................................... Singers $................Organist $................. . Cash Advanced ......................................... ~ ...s.e.~e.s. ....'I'ax..................................... 1
: : : : :::;~:~;:::~~~~~~..::::::..::.:::::.::.:::.:::.j
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Remains to be shipped-see reverse for details.
Interment at............. ID.1L...... JC...l.,"-"'.o.t,......" ....."." .III·..... ".w.·......................... ..
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Lot No ............................................. Section No ............................................ Grave· No .............................................. .
t ...Q.l1 .........:.....................................................................
Ramarks ....................... _o.o.pper.t .Cm.e .... s t .e ..e.l....
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................................................ ;r..Q.§.~.7:'.:t.g.n.... Q!'sip..~.... ±!}.~ .~.r.:.j,.?.r.: ... \~1.Y..~..1.y..e..~.....~.r.:~1ll.... ~.l1: ....c..~.P ru 0 ............................................... p..1.Ji.Ji..sp..~g....Q.P...§.t.~.:t;.... g.Q ..,........{pg r.::t.:11, ..L.................... ......... FO R M 5238 SUPER I OR FUNERAL SUPPLY CORP .. CLEVELAND, OHIO .
Lodges Pall Bear ers
Information Given To: o Relatives o Musicians
p=;::.~:r!~:~;ed
Attended To:
o
o o
o
Cl.rgyman Singers
Permit Bill R.nder.d
344 Date. ____ Augu_ s_t ...2.~.-.-1.952
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF No._ ..._..._._. ___ ._._.____ .._.. _ _
Yearly No .. _____ .__ .____ ._l~- ....--.-.
.E.l.e .r.l[.,t.c..~_
.&... y.a@.:t_.&:....
Date of F uneraL .... _.ll.e_ p-temb.er.....2._....l9.59.............Time........ __ ...... _.. _.. _... _.; ;...f._,_ ~4_, ___ ... _...................
(Style) (No.) Outside Case or Vault.............................. Embalming Body .................................. .. Professional Service .............................. .. Hair Dresser............................................ .. Suit or Dr ess ........................................... . Shirt, Collar, Tie ..................................... . Shoes $..... __ .___ ._ ... __ .. __ Hose $................_._. __ Underclothes ............................................ I Door Spray ................................................ Gloves $..........___ .....__Chairs $.................... Flowers $_ ...........•..._.Pa lms $._ ....... __ ._._.__ Cremation .................................................. 1 Newspaper Notices ............................._.. . Telephone and Telegraph .. __ ........ _... __ .____ _ Ambulance ................................................ I Funeral Coach .......................................... .. Passenger Cars ......................................... . Pall Bearers' Service ............................... . Transferring Body.................................. .. Opening of Grave .................................... .. Cemetery Charges ................................... . Lot ................_... __ . ____ ... __ ............................. . Misc. Transportation ............................... . Shipping Charges ................................... . Clergyman ............................................... . . ........... Singers $................ Organist $................ .. Cash Advanced ........................................ ..
Place of F'uneral Service... _._ ...... .Bh.e.ll ... KnQp._..Q_ hJJr.Qh __ ..Q.f..___ Qh.r.:~..?.~...... _____ .__ ._..._................... _.
..Sale.s..._Tax. .... ___ ..... __ ..__ ............ _. __ .._.
Name..__ ... __ ......_____ .. __NQIl.l:LA1Q_ e.+.:1'... J4H1.!l..•_..____... _._._ .. __ ..... _._. ___ ..__..... _____...__ .. __ ._Sex____ .__..Ill!!,j,.~ _ ..... __ .
___ KnQp.J. __.},!J._I?_f?().\!:EA ...... _.... __._. ___ .___..________ ._______ .__ .__ .. ____ .________________ .__ ..... ___ County___ .___ Jl!?,_ r.;r.;y:.____... _._.____ .ToWDShip.. §!2~+.1._... _!i:P.g.9.. ____ .__ ..____ ..Phone No.__ .._. __ ._______________ .____________ .....
Address_._._. __.._... ______.. _._ ..$.h_~J_1
Where Born. ..___ ._.. _____ .___•._._ ..._. __ .____.... ___ Miaso1lXi_·..._..... _._ ...__ ._____.______._.Race_ .........:8h.lt..e_____ .______....._ ....
--15 __.............. _......................._._.._.. _.
Date of Birth. ... __ .____ J .ul;¥"___.21_ ,...._~Ei!L .. _... _.._..... __ Age._ ... _.. __.•__.__ ..__ .. (Years)
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Casket
(Months)
(Days)
How Long Resident in Community................................................................................................._____...................... . Single. __ ... _._ ..._. ____.. _.. .MarriedlUar.:r.J.'il.Q,.Widowed..._ ........... _....... Divorced.................. __.. Child ...._.. _.. __ .___ .. _........ . Husband, Wife or Child oL_........_...........Mar.Y-.. Jl.lola. ...Go.o.p.er....M1lla...._.................................. . Address .... _.._...._•.__ ._______. __. ___.__._.__...._...............-Shel~ ...KtlD.b7....Miss Q.ur.l ... -.. -............................ Closest Relative_...~,11'.s-.•. -'Ob_le.-.StQCktQn...............:Address. __ ......J..enkins .• _...MO..•.................. Father's Name.._.. .J-ob.r.1.__ .M.i.ll.s..........._.............. __ ..._.. _.....Birthplace,.....................;........._............................ . Mother's Maiden Name._.....D.e~ia... .8.amp.ael............... irth Jace_ .._...................................... _._....._......... _
D.athl~ ...~
Cause of
Date of Death_.___ .Augus.t
Occupation of Deceased. ........f.ar.me.r.. __ ................................ Social Security No ............................................. . Nalne of Employer..........................................._........................................................................................................... . Address ....................................................................._...................................................................................................... . Charge to............ FamiJ.¥....and ...lnsur.anc_ e ..___ ..... _Address ___ .____ ........................................... _............... Order Given By._.........f.arni.ly............................._____ ._.... _.......Address........_._._._.._........ _. _____ ._._.___________ .. __ .. _......... .
Clergyman ........ __Br.Q_•.._Gline.._lianrl.o.c.k_._____ ... __ ..._.. _Cal1 for? .____ .______ .___ ................ __ .. _._. __ ......................
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\
D Rem~.ins
Total Amount.................................. , to be shipped- see reverse for details.
Interment at. .........._.._.. _.J?gj.nter....C.emet.ery................................ ___ ._ .. __ ........._............. __ ._ .......................... Lot No ............................................. Section No .......",.:.... _............................ Grave· No .............................................. . Ramarks .............. _... __ .___.._ !d-51___ Bilv.er..__ .ahaQ,ed... g\!,.D.!!l.'il.t .al.... Jl.t _e.eJ...
_l ..Qh_•...... __ ._____ .. __ .....
..._____............. __ ...___ ._______.l±5.l...al.l...J.y.9.:ry..__ .~:r~_ep..~t~ ....().r.:t:lp_e.... :l,I.1~..e.T .1..().~_ ....................... .._.___ .______ .........__ ...._... _.........._Ml1.j.Q.I.: ... Qg.§.K~.!;...g2..,......... _..._......... _ ....... ________ FORM S23S Sl UPIlR I OR FUNERAL SUPPLY COR .... CLEVELAND. OHIO . '
_._................._____________ ........
Information Given To: 0 Relatives 0 Musicians
o
o
Lodges Pall Bearers
o o
Death Certificate Payment Arranged
Attended To:
o o o o
Clergyman Singers
Permit Bill Rendered
