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FUNERAL RECORD OF Yearly No .... _.._..l.3.2 ...... _...... _...
No•......._.._.._.._ . _ _ _
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Name....... _........_...._......__ ..............................................Link. ...............................................s""........m.a..l~
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(Style) (No.) Outside Case or Vault................................................ .. Embalming Body .................................................. ..... . · ...... ·· ... 1 P rof essional Service ................................ ....................
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nate of Birth. .........................................._............................Ag.................................................................................. . (Years) (Months ) (Days) How Long Resident in COmmunity......................................... __ ............................................................................ :.....
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Date of Death...
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Date of Birth..... ,May.....B......l9.2EL.............................. Ag...................... (Years )
(Months)
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374 CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF Yearly No_ .._...... _.*.3.~
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Date of Birth. ........J..am.!a.r.Y. ....
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(Months)
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How Long Resident in Community......................................... ___ ............................................................................... . Singl.........................Marri.d. .......................Widowed ....................... Divorced(),.1..Y.9.E~.~61ild.......................... .. Husband, Wife or Child 01............................................................... _........ _............................ _.................................. . Address............. _........ _.._...._................ _...........................................................2.221....N.;....H."';r>W-6i}d.............. Closest Relativ• ..Mr.S....... E.Q.S.S.... ,S.......Q.Q.Q.!\;.....................Address... lla J..l...a.a ......'l'..e.X.a.S..................... Father's Nam........Yl......IL._.1l-,§,;r.D.~.r........................_.. _.... .Birthplace... _............................_.......................... . Mother's Maiden Nam.... _...Mat'¥.... E.....,HudSQn...........BirthpJace ... _................................................ _....... Caus. of Death...Q.Q.~~~.r.tqJ~.h.:9.Il!.1?)l..!l.....................::..Contributory.......................................................... Date of D.ath. .... ~ ~, ~9.59 .Hour..................................................................... ...
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Plac. of Death.......Crane,....Mi.s.s.o.Ur..i........................How Long Ill? ..................................................... Physician ....Dr......J .......li. ....YQJ.Ulg ..................................... Address .......g.;r.9"')..~. ,....M6.!l.!l.9.y,;r.l .......... Occupation of Deceased... ....:L1,l.llIl:l.!l.rlll.~.l9: ........................... Social Security No ... '1::'1..':/. ..7.J..g..7:.g,fi..1../p,
Name of Employer........................................... _............................................................................................................ Address ..................................................................... _...................................................................................................... . Charge to....................................................................................... ...Address ................................................................. .. Order Given By...............................................................................Address................................................................. .
9 1959
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No...................._.
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(Style) (No.) Outside Case or Vault .............................. Embalming Body ................................... . ............ ( Professional Service .............................. .. Hair Dresser.............................................. ' Suit or Dress ............................................ Shirt, Collar, Tie..................................... . Shoes $...................... Hose $..................... . Underclothes ........................................... . Door Spray ............................................... . Gloves $.................... Chairs $................... . Flowers $.................. Palms $................. . Cremation ................................................. . Newspaper Notices ............................. _... Telephone and Telegraph ...................... .. Ambulance .............................................. .. Funeral Coach........................................... . Passenger Cars ......................................... . Pall Bearers' Service ............................... . Transferring Body................................... . Opening of Grave..............................._.... . Cemetery Charges .................................... Lot ............................................................. . Misc. Transportation .............................. .. Shipping Charges .................................. .. Clergyman ............................................... . Singers $................ Organist $................. . Cash Advanced ......................................... . S"'l.e.s.....T.ax ......................................... j
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Date of Birth..............12-.,,-7..,,~5;l!;).9.-.......................... ..Age ......... _............................ _........................................ . (Years) (Months) (Days) How Long Resident in Community........................................................._....................... __........................__ ...... _.. ____ .._ SingIe........................Married. ....................... Widowed ....................... Divorced...................... Child.........".ll,.i..l,.Cl. ... Husband, Wife or Child of....•.•....................lInn ... Mar..l..e.. _Tr.u..l.l.1.1 9........................................................ Address ............._............_...._.._........_.. _........................................................................................................................ . Closest Relative __....Ann ...Mar.ie ....T.r.JJ..l.l1J.Q__...... __ ... .Address ..... __ .... ______ ....................... _.......... __ ............ Father's Name...__ .._..Carilo.s...P..e.r.ez ....Tr.u.J.11.lllirthplace... __ ... __ Ar.izonSI._...........................
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Total A Aulount. .............................. ____ I - - - I-_
D Lodges D Pall Bearers
Infor mation Given To: Relatives D Musicians
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D Clergyman
D Singers
At tended To : D Death Certificat e Payment Arranged
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D Permit D Bill Rendered
Insurance ................................................................................____ ......
377 l 9.22
Date. ..D.e.c..eID.b.fLL.~._..
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF No•........... _......_..______
Yearly No .... _......137 _.............. _...... _...
Name. ......_...................... _E.leanQ.r. ...J..QhrHlg.n ... QIi1,.:r.n5l~..................................... S""......r~llI.~.;L.~......
Ca_.................. s sville Missour i ·· Address ....... _........................ _...._............ _....L .......................................... _.............................................. . County........B.a.r.rY-.........._.._...Township......._.._....•..._.............._...........Phon. No ............................ _.............. . Wher. Born............._A ia.s.Qll....J.. ............................ _.._ ...._........................... Rac•.......~~.,l,~.~.........................
Date of
(
Birth........ J .I..I.'J.
(Months)
@
..
How Long Resident in Community.............................................................................................................................
~~::essr:~.::::::.:::::.~~.~;;~.$:::::::::::::::::::~
Singl•........................Marri.d. ... ~.~.r.:!.:.~~.<\\>-idowed ....................... Divorc.d ......................Chiid............................
H asband, Wife or Child of............................ A.d.d.;l,.€l9..!l...Q§!P.n5l~_ ............................ _................................... Address ............. _......._ .. _...._ ......._.. _•._......................Qg..§..~y..Ll,Jg.I... ..!h~_E?g.I:l!..i....................................... Closest R.lativ•. _.... _..Add,l.son...Carney...................... .Address........................................ _ ...................... .
Father's N ame................. _........................................ "" ........ _.. _...~'.Birthpl,ace.............................................................. .
.......... _-
Death~~ ..COritributory'V.~b.!-~.. ~:.::::
Caus. of Dat. of Death ..._.. _......_....................... , ...........
2..........................Hour................................ ...................................~
Plac. of Death...... .Q.~§.§y..U.!,.~... .Q..~.~.~.~p..~E.r.c.~ .c.....!1I'ow~/-rh ? ...•... )~? ... J:l.:r:.~
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Physlclan ........... _..!. ____. __ .~ __ ...... : .....•.......•..... ___ ..... S? ........................ Address ......................... _... _._ .._.. ______ ._. ____ ......... __ .... .
.•..
............
Occupation of Deceased..... hQll.s.~.l1IJ.f..5l............................Social S.curity No ............................................. . Name of Emp}oyer........................................... _............................................. :.................................... .
Order Given By ........},(lQ.JLlXD.rl ...:u.clJ:.[ lfl;t. ..................... _...Adldr<.ss .....•.....,...... :_ ............ Dare ofFu:n.rru........lle~~lDlQe.r......L.~~.... J,~~~~ .............. j:im• .........,~ ...~ . " .~ ., .........1
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Place of F uneral S.:rvi,ce.... _...... lJ.ll.l.ll. !:~ .r...~JL.\ilJ.a.!:Hl. ,j, ............................................. .
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Flowers $.................. Palms $................. . Cremation .............................................. _.. . Newspaper Notices ................................. . Telephone and Telegraph ....................... . Ambulance ............................................... . Funeral Coach ........................................... . Passenger Cars ......................................... . Pall Bearers' Service............................... . Transferring Body................................... ) Opening of Grave............................... _.... . Cemetery Charges ................................... . Lot ............................................................. . Misc. Transportation................................1 Shipping Charges ................................... . Clergyman ....................... _...................... Singers $................ Orga nist $................ .
1
Chargeto........~.a .k.Sllrl ....~ ~'1:Jle~ ... .................................... . _.AO,Oress ................................. .
Clergyman ........Be.V.......Ray.m.ond ... B.lack.....................Call
..
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(Days)
Mother's Maiden Name..............................................:......... :!.~~place_ .. _?i ...... J:.......:.............-.-... -.-_.........
.............. .
Casket :!..:v..~ (Style) (No.) , Outside Case or Vault............................ . Embalming Body .................................. . Professional Service ............................... . •••••••••••• t Hair Dresser............................................. . Suit or Dress ........................................... . Shirt, Collar , Tie ..................................... .
.....................................................................
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............... ... ... ..................................···· 1
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Total Amount.................................. ,---Remains to be shipped-see reverse for details.
Inrerm.nt at.................E.lJ.;r.~l.<;.a._..:;l
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Lot No ................................_........... Section No ............................................ Grave ·No .............................................. . Ramarks ...................... _.. _.... _..
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Information Given To : Relatives Musicians
o o
Lodges Pall Bearers
o o
Death Certificate Payment Arranged
J
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Att.nded To:
o o o o
Cl.rgyman Singers
Permit Bill Render.d
3715
.1.9..5.9
. .
Date. ..... ~~mbe:r.S. __..
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF Yearly No...............:),.3..~.................
No........................_ .._ _
Name. ................ _............-'lI.1.ll.i.eJIl....C.........Q.QQp.5l.r.._ .............._.................................Sex. ............IIl!!:.:),.~..... Address ...........................................E.x.et.e.r.•....Ml.a.a.Q).J,;r..;L......................,...................................................... COunty......Bar.ry..... _...............Townahip ..................................................Phone No ............................ _.............. .
Q..,..........Race........)'1~.1.:~ ~ Where Born............ ~UnJllKl!t...J..
.. ........................
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Date of Birth. .... .Jl.mr.c.b....9.•....1..S.1!±.........................Age....................§.5......................................................... (Years) (Months) (Days) How Long Resident in Community............................~~ ................_~ .....___ ~:~._: .._____.__________ ..__ ... _____................................
Single....................... .Married.lllan::J.I'l.Q,Wldo·wed.....,.................Divorced...................... Child........................... . Husband, Wife or Child of............................................................................................................................................ Address ................................_ ........ _................................................................................................................................. Closest Relative.....Mr.s.....Ld.... E.•.... Sall.P.:...................... .Address...........!';.
•.....Mtf?.s..().\l.r...j,....
Father's Name.......... J.Qbb....c.oOp.ar............................_....:Bii-thplace..._......................................................... Mother's Maiden Name.....Q.~.r.Q.l..tO.~....Q.~1h.l?~fr~a1:~il"t~If'Se5:"S-e.- .............................................. . Cause of Death........._<\.r.t.e.r.io.....B.c.le.I'.Q..t .l .Q...............COntributory......................................................... . Date of Death... J:l.e..Q.e.ffill.ep ... g).•....
19..5..9...::.........:..........Hour ................7...A .·.....I~.~...................................
Place of Death ... .N.e.y..ada. ...Ml.\l.!lg.1lr.:J.......,...·.................Bow Long Ill? .................................................... . Physician ..... _____... __...................................__. ___ ............................. ___ .. Address ...._............................................................ .
Occupation of Deeeased. ......f'.1i\.r mar. .....................................Social Security No ..........l+.9..2~.2Q:.6.l±e\(:'\. Name of Employer........................................... _............................................................................................................ Address ..................................................................... _...................................................................................................... .
CharS'e t
Q•.....l 9.5.9..................Time ...................S...P...,.!i!...................................... Place ofFun~aISffi,,;"~ .. _....~JJ~y.tI.! :... ~~A '~U.Y-'l ...................................... c•••••••••••• ••••••••••••.••• •••••••••••• ••••• ••••• : Clergyman.........RS'll".......ch.as.•..JLa=.aD.dt"'............::CalI 'for L .....................................................
Date of Funeral... .. De.cemh.er....l
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C.J~t!~e~ault......... (.~~:)............ ············1 Embalming Body .................................. .. Professional Service ............................... . Hair Dresser............................................. . Su:it or Dress ........................................... . Shirt, CeIlsr, Tie ..± .. 1 Shoes $...................... Hose $..................... . Underclothes ........................................... . Door Spray ............................................... . Gloves $.................... Chairs $................... . Flowers $.................. Palms $................. . Cremation ................................................ .. N ewspnper Notices ................................ .. . ........... 1 Telephone and Telegraph....................... . Ambulance ................................................ Funeral Coach........................................... . Passenger Cars ......................................... . . ........... 1 Pall Bearers' Service ............................... . Transferring Body................................... . ••••••..•••• 1 Opening of Grave ..................................... . . . .. ...... .. 1 Cemetery Charges ................................... . ••••....•.•• 1 Lot ............................................................. . . .... . . ... .. 1 Misc. Transport.ation .............................. . ....····.. ·.1 Shipping Charg'es ...................................., ............ 1 Clergyman .............................................. .. Singers $................ Organist $............... .. •..•.......• 1 Outside
.!..f.......................
-.. . . . ,~=~::::::::::::::::::::::::::::::::::::::. Total Amount................................. ,
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Rema ins to be shipped-see reverse for details.
Interment at................. .Map~e)!!'O.Qd. ...C.em.e.t.e);:y. .........................................................................................
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•••........• 1 Casket
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SU .. ~RIOR FUNKRA L SUPP L Y CORP .. CLEVELAND. OHIO.
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Lodges D Pall Bearers
Information Given To: 0 Relatives D Musicians
D Death Certifica.te Payment Arranged
o
Attended To:
o Clergyman D Singers o o
Permit Bill Rendered
Insurance........................................................................................ ..
Date....
l.c.f..,:~.~.::.-2.- Ifj-f
CHECK EACH ITEM AS COMPLEI'ED
FUNERAL RECORD OF Yearly No ....
No............_.._.. _•. __. _ _
_.I...3._CZ......_......_...
:::::::~::~::::~:::::::::::.~.~::: :~~~~~~: : : : :.~- .: - : : - : - - - - - - :- - ~- - - - :- -.~=: : : : : : : : : : : : : : : COunty............................•......_.......Township ....... _.._....•... _...........................Phone No ............................ _.............. .
Where Born.............._...•.... _........ _.................................. _.. _....._........ _.............. ___ Race......... ___. _____ ............................. . Dat. of Birth. .................._.._.................._............................ Ag•........................................................................._...... . (Years) (Months) (Days)
(
How Long Resident in COmmunity.............................................._................................. _... __...........__ ........................ . Single........... _............Married. ........ __ .......... __.Widowed..... __................ Divorced...................... Child........................... . Husband, Wife or Child of................._............................................_...................................... _.................................. . Address ........•.............. _.._...._.._............ _........................................................................ _.............................................. .
Closest Relative._.... _........... _....._.............................................. _Address ........................................~........................ . Father's N ame............._.._...•__...................._...................._.._.....Birthplace... _................ :....................................... . Mother's Maiden Name..._............................................................Birthplace..._........................................................ . Cause of Death...............................................................................Contributory.. :.'.... .................................................. Date of Death ..._........................................................................... .Hour.........-...~ ........................................................._, Place of Deatb.........................................................................-...... .How Long Ill? ................................................ _.... Physician.......................................................................................... Address ................................................................. . Occupation of Deceased............................................................... Social Security No ............................................. . Name of Employer........................................... _..._...................................................................................................... . Address .............................................................................................................................................................................. Charge to....................................................................................... _.A.ddress .. ,:~ ............................................................ .. Ol'der Given By..............................................................................Address ................. _.............................................. . Date of F uneraL ......_!..2. ...::_I7..:::...
.!.'i.?:..Q.......................Time........................................................................
Place of Funeral Service............. _.... _............ _........... _.. _........................... c:........................................................... _. Clergyman........._.............. __.... _.........._.......... _............................. Call for? ............................................................__ Address..........._...................................................._:..................... _.........._.......................... _............................ _...... _.._.
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Cask.t ·::: ..
J.!a'l~tt....tff).................. $..................
(Style) (No.) Outside Case or Vault................................................. . Embalming Body .................................... ................... . Professional Service .................................................. .. Hair Dresser.............................................. .:............ ..... . Suit or Dress ............................................................... . Shirt, Collar, Tie.................................................... .... .. Shoes $......................Hose $......................................... . Un,derclothes .......................................................... ...... Door Spray ................................................ .............. ...... Gloves $....................Chairs $............................... _...... . Flowers $..................Palms $................................ ..... . Cremation ..................................................................... . •........... 1 Newspaper Notices ............................................._....... Telephone and Telegraph.......................................... .. Ambulance .................................................................... Funeral Coach ............................................... _............. .. Passenger Cars ........................................................ .... .. P all Bearers' Service........................................... _...... . Transferring Body.................................... .................... Opening of Grave...................................... ..._............... Cemetery Charges ........................................................ Lot ................................................................................. . Misc. Transportation .................................................... Shipping Charges ....................................................... . Clergyman .................................................................... Singers $................ Organist $..................................... Cash Advanced ..............................................................
==:::::I: ..: :. : : . :.:.: .: .:: : : :::.:: :.: .: : : : :.: : .:.:... i:::: ~:: : : :::::: Totsl Amount.................................. - - - __
Remains to be shipped-see reverse for details.
Interment at................. _........ _........ _.............................................................................................................................. Lot No ............................................. Section No ............................................ Grave No ............................................... Ramarks ......................._................................................................................................................................................... .
o
Lodges D Pall Bearers
o o
Information Given To: Relatives Musicians
o o
Attended To: Death Certificate Payment Arranged
o o o o
Clergyman Singers
Permit Bill Render ed
Insurance ......................................................................................... . FORM 8238 SUPERIOR FUNERAL SUPPLY COR P .. CL.EVEL.AND, OHIO.
Date. ...DfHl.e.mb.e.L .1.9.......l.9.5 9
CHECK EACH ITEM AS COMPLETED
® Casket c. •.(S~~;::J?!?r.y..~~~~.§.........
FUNERAL RECORD OF
t..f:
Yearly No ..................·}.;;1t!iLt..
No...................._ _ .._ _
s ... Ar.y..l .1 l a ...BllIlt i n.::.:..............................sex. ......male........... Address ...............................................P.u.r.dY..•....Mi s.s.o.ur.i....................................... ~~ .................................... . Name. ........................................Au.d i
COunty...... B.al.T Y.......................Townsbip ......."!Q.PQ.l1
g,..................Pbone
No ................................., ...........
Wher. Born. .............13.Q.Qn a...QQ.y,!l~y..•.....+.n.9J:§:.l}?:.......................... :.Race................'Y.l?:.1..~.~
...............
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Date of Birth..........J.l}..lY.....d5.,.....l
1$.g?.3..................... Ag•.....................7.§....................................................... (years) ····
(Months)
(Days )
How Long Resident in Community.................................................................... _...__ ..... __ .............................. _._....... ___ _ Single........................Married. ....................... Widowed....... ~~~.O'.~lm~orced...................... Child ........................... . Husband, Wife or Child of............................................................................................................................................ Addres............................................................................................... 0•••••••••••••••••••, ..... . .... . ............ . . ... . . ... . . . . .... . .. . ....... . ..... . Clo.est Relativ•. ..Mr.s..•...N.an a ...H.a.YJ.Qr .:th................... .Address........f')J.r.g..Y..,.....Md,.?·J?9.!d~J ......... Father'. Name. ....B..Q.VL~..:r..!L ..!iQ.)Y~.r.g... £?!dn.~JD...........Birthplace............................................................. . Mother'. Maiden Name........ .!'!" r.:tha ...P.i Cau.e of
p.a r..................Birthplace.............................................................. Death....conge.s.t .i J[e ...h.ea r .:t. ...failJ.l..:r..e ontributory.............7X:t(l.r.),,9..?.Q .!l.r.Q..§.~ s
Date of Death.. .1!.a9..~.mQ.(l.r....
19..,....J9.5.9........................Hour ....................2... A.•....lIL..............................
Place of Death ...........hO.m.e ....................................................... .How Long Physician .........Dr .•....N.a.el ...T.•... Ha....r.i Occupation of Deceased....... .f.ar
Ill? .....................................................
.e....D..,.... Q..,.... Address ..............P..y,~
~
Outside Case or ault............................ .. Embalming Body .................................. .. .... · .. · .... 1 Professional Service ...................... :........ . .. ......... . 1 Hair Dresser............................................ .. .. .. · .... · .. 1 Suit or Dress ........................................... . Shirt, Collar , Tie ..................................... . Shoes $......................Hos. $..................... . Und.rclothes .abJrt.",.t .i,e.",.s.o.X .. Door Spray ............................................... . Gloves $....................Chair. $................... . Flowers $.................. Palm. $................. . Cremation ................................................. . Newspaper Notices .................................. Telephone and Telegraph....................... . Ambulance ............................................... . Funeral Coach.......................................... .. Passenger Cars ......................................... . Pall Bearers' Service ............................... . Transferring Body................................... . Opening of Grave..................................... .
ms.r. ...__ ....................... __ ...... Social Security No ............................................ ..
~::~~.~~~. .~~~~~.~~::::::::::::::::: :::::::::::::::::::1
Name of Employer ........................................... _........................................................................................................... .
Misc. Transport ation .............................. .. Shipping Char ges .................................. .. Clergyman ................................................ Singers $................ O rga ni s ~ $................. . Cash Advanced ..........................................
Address ............................................................................................................................................................................ .. Charge to............f..amJJ x ......................................................... ...Address ................................................................... Order Given By.·...........f.aml.l,y. ............................................. .Address ................................................................. .
?J'..,.M.:........................ Place of Funeral "e'''''':e.................,.e...",.t.,....... ,,.,.......................................................................................,....... Date of Funeral... ......... n ea.e.ro.b..er ....2.2 .•....195.9...........Time ..............................
.S.a.l~..a....T.I?Ji!:...................................... .
Clergyman .............Re.iL_ .. Eo....N.e l.aQn .............................Call for, ............. :.: ....• .
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. ................. ..... .... ... .. ........ .. ....... .. .............. ... 1
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Remains to be shipped- see reverse for details.
Interment at................12Q.ar lr..§ ....Q.am.~ .:t;. ~.r.:y..............................................:....................................................... Lot No ............................................. Section No ............................................ Grave No .............................................. . RamarkB ..............................2.3.0:1l....1±93. ...br .Q .uz..(l.... s.\1.?9&9.....:1e...gh.,...:.................................................
Ro s etan Crede chine-Louri e with Motif ................................................................................ ......................................................................................................... .. ~
.......... ... ....................................3....1
,.ORM 6 235 SUPERIOR FUNERAL SUPPLY CORP .. CLEVELAND, OHIO.
11
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I
Lodges Pall Bearers
Death Certificate Payment Arranaen
'":"::~
I
o -\:jMfit.Vman v
0 Relatives 0 Musicians
Attended To:
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n
Singers
Permit Bill Rendered
Data .........~.•. _.2.1, .. _.~~
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF Yearl7 No •... _.._.. _.l~~....-......-...
No•... _.. _.._......_..__. _ _
Nam......... _......................_..........Ji9.-.r.!l:h....!l!.:....X'}~!~.~.r.:.............................................Sex. ................f..~.~.le Address ... _............................_.........Q.a .6J!.y..U .le.•.....!4J.1l..s9.9.r.J..................................................................... County...... I'!.~r.:T.Y......_......_.._...ToWD.hip ....... - ........•... _...........................Phone No ............................ _.............. . Wh.re Born......B.ar.r~._.~Q]J.!l.t.y..•....M 9...,........_.. _.............. _.................Race.....?!l}.:L..t..~...........................
(
Date of Birth. .........O.~.t.Q.b..e r....
12.•....1~.6.!L........ Ag•................................. ~l.......................................... (Years)
(Months)
(Days)
How Long Resident in Community........................................................ _...................................................... _._ ......... _ Singl•........................Married. .......................Wldowed.......II'J.~.c).V!fj~orced...................... Child........................... . Hu.band, Wife or Child ot............. Lafayf:.t .t.f: ...P..l1\!ll!Jl.\l.r........................................................ _............... Address ....................... _.. _...._.. _........ _.._........................................................................................................................ . Closest R.lative._.... J~:r.S..•.._BQJ.... l1.
ng,.e.r .lL.............:Addres•.......... g§:.El.§.Y.~.~.~.E3.~.....1.!~El..s..~.u.:r i Father's Name....J D.el...3._...p..e.r.r.iman............._.._.....Birtbplace........ ::........ ~...:.............................. _...... . Mother's Maiden Name.........E:l.1z.
9.5.9..................Hour ....................J,.:..~Q...?..:.M..~ ........................ Place of Death.Sunae.t ... .Y.ally....Re.s..t ... Ho.mf: ........How Long Ill? .................................................... . Physician ........ p..r..,.... G:..,.... A:... J".~.ry..~.~ .............................. Address ................................................................. . Occupation of Deceased.. __.__ ....h.Q.1U?~Y{~f..€?......................... Social Security No .......__ .................................. __ _ Name of Employer ............................................................................... _.......................... ___ ._ ......................................... . Addr ess ........ __ .. __ ... ______ ____ .__. __.....__............................. _............ __ ............................... __ ....... _. __ .. ___ .. _.... _.. __............... _....... ___ .. Charge to ..............farn.il
y ...................................................... _Address .................................................................. .
Order Given By......................f... m.i .ly. .................................... Address ................................................................. . Date of Fun.raL. .........D.e.Q.e.mb..e.r..... 2!±.•...) 35.9. ...........Time ..........................g... :t>.-'_~~~.~
............................
®
Casket .."Yau.lt.................................... (Style) (No.) I Outside Case or Vault. ... ___ ......... __ ..... __ .___ _ Embalming Body ............ __ .. ______ ... __ ........ . ············ 1 Professional Service ............................... . Hair Dresser............................................. .
~~~!t~rc~~::: ;~~::::::::::::::::::::::::::::::::::::::I Shoes $......................Hose $...................... Underclothes ........................................... ........... Door Spray ..............................._............. . ············1Gloves $.................... Chairs $ ................... Flowers $.................. Palms $.............. Cremation ................................................ . Newspaper Notices ............................. _.. Telephone and Telegraph ....... _........... _. Ambulance .............................................. . Funeral Coach .......................................... . Passenger Cars ........................................ . ............ Pall Bearers' Service .............................. . ............ Transferring Body................................... , Opening of Grave ............................... _.... . Cemeter y Charges ................................... , Lot ............................................................ Misc. Transportation ............................... Shipping Charges .................................. . Clergyman .. t--::................................... . Singers $................ Organist $................ . Cash Advanced ........................................ .
1
...!
Sal es....Tax. ........................................ .
P lace of Funeral "el""':e.............!I1~••"..o,.""..."...;"."'._,"-"'''.",."."..~, ....c;.,.,. ::-::-....~.:·.,........................... . Clergyman.........Re.v:._.~ohn....S.l!!af.f.Qr ........................ Call
(
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Remains to be shipped-see reverse for details. Information Given To: 0 Relatives 0 Musicians
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Lodges Pall Bearers
.................................J.Y.Q.r.y.....9..:r.g.~.9.hJ.t1.~.....s.h.El.:r.~9:.".!l: ... ~I.~ ~ .. El.~
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Death Certificat e Payment Arranged
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Insurance ......................................................................................... .
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Date. .• .D.£H~ruu.Qg ...._..Z.l
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No•..._.._.. _......_..____
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Name. .._.._...................... _ ........._..M.ar.y. ....Lj,.L\..;hIMLJ.ng
COunty..........................._.._.. _.._...Township ......._............ _........................... Phone No ............................_............... Where Born. ......S.Q;r.JI1.E.f.J.I1.15 L .....!4f...I~u~gy._r.L... _...........................Race ............Y'.~.i..~.e.
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Date of Birth............AP.I'.l;L.l .Ij..•... ),.$..z;;.............. ..Age ...............?;,.?.................................................. _....... (Years) (Months) (Days) How Long Resident in Community........................................................_..._.._......_....._...._.... __ ...................... __ ........... .
Single........................Married. ....................... Widowed ...W.l.o'QW.e.dJivorced ......................ChUd ........................... . Husband. Wife or Child oL ..................D.r......
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Address ............. _........_.. _..__.._...._...... _..........................................c••••..••••..••• ···:J:1Q5···-Elet-s-t'···2 -l:st···:P-:J:a;c e Closest Relativ•.......... D.r..•_.E.•....B..•....Ing;r.am...............Address .............T.l iJ,.aa.....Qk.lah.Q.01a..... Father's Name..... ,J.ohn...B.r.e.s.b..ear..a.................._.. _.....Birthplace•................................ _.......................... . Mother's Maiden Name.................................................................Birthplace ... ___ ............................................. __... _... . Cause of Death..................................................... _........................ContributOry...................'........................................
Date of Death... _..D.eO.e.mb.e.r. ...21.•....195.9....................Hour......................................................................... Place of Death........ hQJ))jL....................................... _, ............... lIow Long Ill? ...................................................... Physician.......................................................................................... Address ................................................................. . Occupation of Deceased.. .............................................................. Social Security No .............................................. Name of Employer........................................... _.......................................................... :................................................ . Address ............................................................................................................................................................... _........... ..
Charge to ............Dr ._.... R _.._B. •....lngram····· · Mrs··: ···;rA.ddg~s" Tngr'iii'ii""" "" "" """"""" " """ ""'" Order Given ByMr.s. .• ....R. •... B..•....lng;cam.::-....................Address ................. _........................ _..................... Date of Funeral... ...... .D.fl.C.~.!J)b..e.r.....?3 .•....195.9..............Time ..................t;...l'.,.M.,.................................... Place of Funeral Service.......C.ulv.er..!.fL JJhap.a l
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Clergyman .... B.1.l.V.X'....".11!1 ...E.:k9.Y.Q,...ti.9.1 y....................Ca11 for? ......: ......................................................._
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CHECK EM~E ITEM AS COMPLETED
FUNERAL RECORD OF
6V Fl.?f{t-serVlc e s
outside Case or
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(No.)
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............ E mbalming Body
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P rofessional Service ············IHair Dresser ....... ... 1 Suit or Dress Shirt, Collar. 'ri , Shoes $......................Hose ~ . U nderclothes Door Spray Gloves $.................... Chairs S F lowers $.................. Palms 0 Cremation N ewspaper Notices T elcphone and A mbulance F uneral r.ntH"h . P assenger ~ , P all Bearers' Transferring 'Rt"I~ , Opening of (l,."v. Cemetery . .. L ot M isc. .. Shipping Charges Clergyman Singers $................ Orge,nist !t. Cash
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Lot No ............................................. Section No ............................................Grave
Ramarks ....................... _.. _.!±&0.-;!:;"'2.8.6 ... .6.il
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FORM eaS8 SUP ERIOR FUN ER AL SUPPLY CORP., CLEVELAN D, OHIO.
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Information Given To: 0 Relatives Musicians
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Interment at................. _.......Qak..lll ll
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Singers
Permit Bill Rendered
Insurance......................................................................................... .
J,.'i5 9FUNERAL
Date. ...nel:llllllber....22.....
CHECK EACH ITEM AS COMPLETED
RECORD OF
.......-......-...
Yearly No.... - ..... ~!!:9
N o•....... _.._...... _..__. __
............. , Casket (No.)
Name. ...... _.............._.............Edi.th...Elizaheth...England............................ SeL ...... f..em6.1.e.... Address ................................._.....Exe.t.e.r.4.....~,U.$..!l.Q .Wr..t. ............................... _............................................... . COunty...... BaIT:Ir......... _.._.._...ToWDBhip....... _........•... _...........................Phone No ............................ _...............
Where Born..............._......__ ........ _.................................•.... _ ...._........ __ ......... _____ .. Race. __ ._0_ •• ________ •••••• •••••••••••••••• _•.••••••
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Date of Birth. ........ _~.r.il
....9.•....l£1.S.9......................Ag•....................1.Q....................................................... (Years)
(Months)
(Days)
How Long Resident in Community.......................................................................... ___................................................. Single........................Married. .... Ill.~E~.~.~idowed ....................... Divorced...................... Child............... :........... . Husband, Wife or Child of.............................Cbi.>J::J.e.s.... E.,.. Ji;ngl~n.\'h ..............._.................. _............... Address............. _........ _........_.._........__.............................E..x.:~.~ .e..r.:!.
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Closest Relative._ ..HU.sband. ................_...............................Address........................................ _ ...................... .
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Cause of Death.............................._____............................................Contributory ..................................................... _... Dat. of Death ..._..........Il.e.c.emb.e.r.... 2.2..•....
.l.9.5.9............Hour...................3.... A.,....M.,.......~.......................
Place of Death....Phe.o.nlx •.... Ar.:l. ...Qn a ....................... .How Long Ill? .................................................... . Physician .......................................................................................... Address................................................................. . Name of
Securit~
1..J..r.:::.l..fc::.Z<>..:.EJ.,f?: Employ.r ........................................... - ... - .........................f...d..i..I:k..!.e.~A.J:;:'r.::<-I--y.(".~.,...........
Occupation of Deceased. ........ho.uSelH.if.B ........................Social
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Address..................................................................... _...................................................................................................... . Charge to............. Ru.s.b.and. .................................................. _.Address ................................................................... Order Given
Embalming Body ............................. ......... --[-..............--[-.... . Professional Service ................. .................. ,................. ,..... . Hair Dresser....;::"JL,.. ;;................................. --[- ........c &tit 8F Dress ""':"":.,.,"":............................. •••· ••••• ••• 1 Shirt, Collar, Shoes $......................Hose ~........................ I................ I ..... Unde.rclothes Door Spr8,y .................................................. , Gloves $.................... Chairs $................... . Flowers $.................. Palms t ................... Cremation ....................................................--[-.. _1.. Newspaper Notices ..................................... ,... .........: ············1 Telephone and T.leg,.aiph....... _................ Ambulance Funeral '-'oae" .............................................. , Passenger vars ... ........................................ •.. - ....... , Pall Bearers' Se:rvice·································I···········_· Transferring Doay. .................................... 1 ............ , Opening of lirav'•........................................ 1
D~c .........................• : .a~.~ ~~: . 7 ...... ~.=.:: ~ .............Aclares':............... ~ ... ~ ...:
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Date of FuJJ&'u ............~~y.~~!y. S,£ ...G..£ •.... ~~2~~Z ............ j:im'•.................... ~ ... ~ .. , c~~
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•••••••.•••• 1 Lot
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Place of F uner al :;ervJce..._........ _." .""' . y..>,.~_ Clergyman ......... S.1.1e.L _Md... Y..€l.I1Z.6.!l9...!;.....................Call for I ......................... ........,
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Remains to be shipped-see reverse for details.
Interment at................ .Jyl?JlJ,.~l~Q.9.g.... .9.~!!!.~.1;.~.r.:y..........................................................................................
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Information Relatives Musicians
Death Certifica te Pa:vment Arra m~'erl
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Clergyman Singers
Permit Bill Rendered
Date. .•.•.De.c.amb.e.r.22.f-.195 9
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF
;!..!±f:............... Name. .............................. _NanQy.....Y.J£KtD·J §. ... 9::r:!?:h.!l,Il!........................................Sex. .........f..e..~.J.:~ .. No........................_ .._ _
Address ........................................!y.~!il}P.}.:l:r:!).•.... M.~.~.f:l.'?~:r:.~.....................::........... .......................................... County.. ~.
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a¥.l1e...D.o.unty..•.....1.l.l1n.Q.1,1I-. ..........................Race .................XI.h;i,.~.e................
Date of Birth......AQ.: rJ.;LJ.3., ....
Casket
Yearly No ..............
J£f?2......................Age......................... T2.................................................. . (Years) (Months) (Days)
Row Long Resident in COmmunity..............?.Q...Y..e..§,r.'.!?. ..................................................................................... . Single....................... .Married. .......................Widowed.~.)yJ.g,Q.YLe..%ivorced...................... Child ............................ Rusband, Wife or Child of.........................I.ac.o.b...P. .•....a-.r.al:\.am............ Jfl.e.g.~.g..?.~.(~\.2 ..................... Address .............................................................................................................................................................................. Closest Relative.....Mr..s.......Buth..JL'l.lllie.r.J:).9.9..l ....... .Address.. jy.g,.@p..~r.!}.J.....M .!.§.§9.l;l.r.;b.... Father's Name....I.ab.rL.Gr.Cl.l1.e ............................................Birthplace..............................................................
Mother's Maiden Name.....1YgJ,.(l.....p..:r.~ J.t!;.....................l!irthplace..........~ ................................................... Cause of Death.................... ____ .__ ...... _............................................Colltributory__ .......... __ ........................................... .
Date of Death...........D.e.c.emb.e.r. ....~.2.•....
J.9.5.9................Rour ........................................................................
Place of Death...... .Y.aml!'!.r. .. g,Q.± ...!}g.!!!.e......................... .How Long III? ................................................... ..
Physician .. D..r..~....Qh.a.(l..,... IL.... p..r.9.Y !n........................... Address .......... 1'.~.1..~.€!~l.!l..ll:l .....I~:i.f:l..S..~.U.Ti Occupa tion of Deceased.........hQ.lUl.W.e.l
.t:.e......................... Social
Security No ............................................. .
Name of Employer ..... _____._ .. ___ .... __ .. __ :~_ ............._... _........................................... :........................................................... Address ..................................................................... _...................................................................................................... .
Charge to....... ln.sur.anc.e ......................................................Addre~s ................................................................... Order Given By........... Y.lr.glnia ....G:r.ah.am..................Address................................................................. . Date of E'uneral... ........D..e.C.fLIll.P..\'lT ....(;] ..... Time ...................? .:.2~~ ~.1v1.~
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, Prof'essional
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Place of Funeral Sell'Vi"e........!:;J3..sLU)_\J.r.rL ..!:la,q.lU..tU,...jd.1, .~}.,:.\1,; L ........................................... Clergyman......... _...
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Total ARemains to be shipped-see reverse for details.
Interment at.................J:r.IiI.§h.9.l.\r.n...p..:r.~J.r..~.!1... .9.~!1l.E!.!;..~!..Y........:........................................................... Lot N o................................ _........... Section No ............... _..............·.............. Grave No ............................................. .. Ramarks ................................#.!±;l.9.Q... g.r..aY. ...hing,!1.. g .§,Q ....~.:te..e..;L. ...................................................... .
whit e s a _tin tw il l i nte--r.....io r ................................................................................ .. _....................................... -- ..................................................... .. .............. ....................................J 3p.r.lngf.1.e.1Q.... Q.MK~.t..ly!fK: ... g9.......... ............. ................ FOHM 11 2. 315 SUPERIOR FUNERAL SUPPLY CORP .. CLEVELAND, OHIO.
Information Given To: 0 Relatives 0 Musicians
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Death Certifi<:ato
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0 Clergyman 0 Singers
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Permit
(Boone) Yearly No•... _.. _.~YJL
No........_.._......___._ _
1.he.aDOn.... is.6.Q.llr.L .............._...............................................
COunty..........BarXy....._.._.._...Township......._............_........................... Phone No •...........................................
Where Born............. _..Mis.s.o.llri.........................._.. _ ...._........................... Race.................. .Y!.t\J.t.\L ...........
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Dat. of Birth......................._J?~g.§t!!!l!.!'.l.r.....
?9..L)·§4r;t....................§~........................................... _....... (Years)
(Months)
:=...~. ..@. ....................
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Name...••.._......................_.........._..9.r..L ....tig.!l~.§t .......... _.......... _.....................................Sex. ..... J.e..lnJ!}~ .... Address ................................._........ _.. _....
CHECK EACH ITEM All COMPLETED
(Days)
Casket ..
::::::::::::1~:~. o~r~~:~:::::::::: :::::::::::::::::::::::::::::::: :::::::::::::: ::::::
:~::::::::::r :~::~ ~~~.l.~~~..~.~~~~~ii·~:~··$:::::::::::::::::::::: : :: : : : : : :::: : Underclothes ............................................ .............. ...... Door Spray ................................................ .................... Gloves $.................... Chairs $.................... ..........._. ...... Flowers $.................. Palms $................................ ..... . Cremation ....................................................._......_....... N€~rspaper Notices ....................................._......_...._. Teiephone 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 .......................................... ................... .
How Long Resident in Community............................................................. __ .. ____ .. ____ ................................................. .
Singl•.. S.lng),lL.Married. .......................Widowed .......................Divorced...................... Child............................ Husband, Wife or Child of....._........................................................ _............................................................,.............. Addr.ss ............. _........_.._._._.._............ _.........................................................................................................................
. • ._..._ M r s ~...... Orville Ber ze il .Address ........................................ l'ftl e a t on , M_i....................... s souri . Closest Relativ ......... ...._......... _...............................
Father's Name............._.._ ... _........_.................................._.._.....Birthplace... _......................................... __ .............. Mother's Maiden Name...................... __.........................................Birthplace."l.. _.............. _......................................... Cause of Death............................................................................. .-. Contributory..........................................................
Date of Death..._D.S.c..e .mb..e r....
23..,.....l9.5.9. ....................Hour ........................................................................
Place of Death...........HOJllS.............................. _........................ .How Long Ill ? ..................................................... Physician ....... _................................................................................. Address................................................................. . Occupation of Deceased............................................. _................ Social Security No ............................................. . Name of E mployer........................................... _..._...................................................................................................... . Address ............................................................................................................................................................................. . Charge to....................................................................................... _Address ................................................................... Order Given By..............................................................................Address................................................................. . Date of FuneraL ......_....D.e.QSlm.1?e.r.....Z.9.J.... Time............. .2... )'..
J9.5.9.........
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Plac. of F uneral Service..._........ _....Y.lhe.a.i;.9..!l...J??-..P..~.J.§.1;.... Qh.1l£c::l:t.................................................. _.
Clergyman.........YL,....P...,_..BJ.Qh.Ii.;r.~l?Qn::.)i; ....... Q..:.... T.~f1£lP.:r' .........................................................• Address..._......_............................_......................_ ..............................__..._..................... _............................_...... _.._.
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(Style) (No.) Outside Case or Vault................................................. . Elubalming Body .................................... .................... ..···.. ··.. ·1Professional Service ....................................................
...................................................... ················1·· ..······..·· ...... - _••..... / ...................................................................... .................... _._ ... / ...............................................······················· 1- -,
Total Amount. ................................. - -- __
Remains to be shipped- see reverse for details.
Interment Bt..................Bolilq...i1.a Jllf Qr..t ....Q.eJlls .t..e .:ry........................................................................... . Lot No ............................................. Section No............... _............................Grave No ............................................... Ramarks ....................... _.. _............................................................................................................................................... .
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Lodges D Pall Bearers
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Information Given To: D Relatives D Musicians
Death Certificate Payment Arranged
Attended To:
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Clergyman Singers
Permit Bill Rendered
Insurance.................................................... .................................... . !'"ORM e :uul SUPERI OR F U N ERA L SUPPLY C OR,. .. CL EVELA ND. OHIO .
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Date.............__ .Dec.e.JTI..b.e.r._2..1.,
195 9
CHECK EACH ITEM
FUNERAL RECORD OF No........................_.. _.._ _
Yearly N o.... _......_........
J!±j,.........
Casket
J!.+..s..!?!?!,!.r..t .................................................. ...... ..
COunty..............Ba.r.r.Y......_..._..Township....... _.._........ _...........................Phon. N 0 ............................ _ ............... Whore Born............._....JLU.
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Date of Birth. .......S.S.p .t.BJnhe.r.... 2!±.~.... lS.7.;3. ....... Age...............8.6. ........................................................... .. (Y.ars) (Months) (Days) How Long Resident in Community................................................................................... _.......................... _................ Singl........................ .Married.. Jnarr.ie.Wridowed....................... Divorc.d ...................... Child .......................... .. Husband, Wife or Child oL....................... G€-orge. ..l¥.i-erman._................................................_............... Addres........._... _.._._." .._..._ ....... _ ......_.... _.................................................................................................................. . Clo.est Relative...... Mr.S.,.... ~
ab.J...e....D.lJJI\ffi.1Ji.t ..............Addres.......... JQD.e.t..t ...... li1..s,flQlJ.r .1......
Father'. Nam.........J.,.g,)j'.f\
fu&..... J .. .. . ...k.(-d:~ ......Contributory..r.tkk.I1!::l;,~~.L ... :....... fj,..~ fl..:..?£..f!.m...........
Date of Death... _....P.~tQ.e.m);).~.r. ....£.l. ..... .:J,.9.5.9..................Hou;.: ..:...................~...... Plac. of Death .. ...2.Q;3.....C.QJ.lnt~.... Rd'"
iQnilt.t ......Mm:ow
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Long Ill? ...........
Physician ........·I).r.......·F.r.flnkK·sr..];'..........·........................ ··.. ·Address ...........~ one.t.t.)..... M.1-S-~Q\J..];'.i ... Occupation of Deceased. ......hg.l\.S!.~Y!.tf..~........................... Social Security No ............................................. . Name of Employer. __ .. __ .__....... ___ ....................... _... _............... __ ..................................................................................... . Address .............................._................................................................................................................_............................. .
Charge to..........Husha.nd...&... dau g..l-:!.t .e.r.S............... ...Address ................................................................. .. Order Giv.n By............ family.......................................... _.. .Address ................. _............................................... Date of FuneraL ......D.e.,Q.e.mJ:2e..r... ..3.Q.......J9.5.9...............Time ....................~... I).,...\L ............................... ..
~.9:: ..~ .. @L .......:.................... $................ ..
(Style) (No.) Outside Case or Vault.......... ____ .................. __ ... __ .... . Embalming Body ................................ _.......................
Name......._...........................:rsj,a... P..a.r..l!:l.~.....E:."'g.J& ..Y{.~§;r.~n............................S.x.....f.mm.a ls....... Address................................._................ 9_~.!?.S!y.JJJ;.!:l.,...
e "
AS COMPLETED3
:::::::::::1~:~es~~e::~r~e~~i~~.:::::::::::::::::::::::::::::::: :::::::::::::: ::::: .. .......... ' Suit or Dress ....................................................... __..... .. Shirt, Coliar, Tie ............................................ _............ . Shoes $...................... Hose $........................................ .. Underclothes _.............__ ............................ ..... _............. . Door Spray ........... _..................................... _...... __ ........ .. Gloves $.................... Chairs $...................................... .. Flowers $.................. Palms $...................................... Cremation ............................... __ ........... __ ....... ___ ...__...... .. Newspap er Notices ... _... __......................... __ ........ _. __ ._. Telephone and Telegraph ............................................ ' Ambulance ............................ __ .................. __ ....... __ ........ . ............ Funeral Conch ................__ ....................__ ....... _.. __.__...... .. _.......... Passenger Cars .......................................... .. __.............. .. ............ Pall Bearers' Service ................................ ____...... __....... . .. ....~. ___ . Transferring Body.................................... ................... . Opening of Grave ................................. __ .................. _... . Cemetery Charges .................................... ... _....... __ ....... Lot ................................................................................ .. Misc. Transportation ........................... __ ................... __ .. Shipping Charges ....................................................... ~ Clergyman .................................................................... Singers $................ Ol'ganist $............................_......... Cash Advanced ............................................................ ..
Place of Funeral S.rvic................ .G.u l:v..e.r.!..a...Gha;p.e.l...............................................................................
Clergyman..... Re¥..,....Q ....o;r....... An;pe-d-!3..~.~~... y.!.e.~:t:W for? ................................................................ Address..........._....... _......._.................................... _...................... .
(
D
Remains to b. shipped-see revers. for details.
Lot No ............................. __ .............. Section No ............... _....... .
....ch........................................................................... ...................................................Y./h.~:t..e ....s.ll..tJ!J.....t.YLi.JJ.... .+.n.j;.~.:rJg.r. ..................................................... ......................................................J2.@_-::W.~lJ....g.a.f?lf.~.~....Q.Q..,.................................................................... FOR!4 52311 S UPKRIOR ,..UNERAL SUPPLY CORP •• CLEVELAND, OHIO.
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Total Amount.................................. - - - - -
I
Interment aL .................._.... CaJ..to.n... C.eme.t.e.r.y....1 Ramarks .............................blu.e....f.igur.ed ... o.c.t....
.. .................................................................. .,.
Information Given ' To: 0 Relatives 0 Musicians
o o
Lodges Pall Bearers
o o
Death Certificate Payment Arl'anged
Attended To:
o o o
o
Clergyman Singers
Permit Bill Rendered
Insurance..............................................................................._........ .
3&f> CHECK EACH ITEM AS COMPLETED
Casket .. &.. ·,Vau.l.t................................ $..7.9.5...:":: .. (Style) (No.)
Yearly No .... _...... l.~~...... _...... _...
No................ _.. _.. _......__
Name. ......_......................_........ J.o,S.e.ph ...l'I.a.sh.ington ...Rohi.s.on.................. Sex...........male. .... ..
...
Address ........................................... _Q1HHl.Y},...+.J.~-' ))J.§!..!?9.W.,1, ................. _.......................... ................ .. County..............Bar..r¥-....._.._...Townahip.......l!!!ineral....... _.... _.....Phone No................ _.......... _............. .. Where Born............. _.-F..-"~'l;;l.~.s....C'OU.nt
lf.y.... E
(Months)
Outside Case or Vault................................................. . Embalming Body ....................................................... . ............ , Professional Service ................................ .................. ..
:::::::::::1~~~ o~r~~:~.:::::::: : : : : : ::: : : : : : : : : : : : :::::::::::::::::::
3. .9.5
............ SfilO:10Ciillii'f, Tie.&lInde.r.J1I[.e .a r...... ..........
(Days)
Shoes $....... _............. Hose $...................... ..........._..... .. Underclothes ............................................ ................... . Door Spray .............................................................. .... .. Gloves $.................... Chairs $............... _............. ~ .. ..
How Long Resident in Community........................................................................ __ ._ ........ _._......_.... _____. __ .................. .
Single........................Married..mar..r.ledWidowed ....................... Divorced...................... Child........................... . Husband, Wite or Child oL .......................E.B.:th.e.r....Rohi.Bon._ ............ ~............... _.................. _............... Address ............._........_.....__ .. _...._..___....................D.as.8y..ll1e...... iis.B.ollI'.l ..................................... .. Closest Relative..... E.s.ther....Robison......................... .Address ........................................ _...................... .. Father's Name....... .P..Qw.e l l .. .Robill.B.Qn ............ _.. _.....Birthplace............................................................ .. Mother's Maiden Name..... .B.e..t..ty....J.!nkD.9..w.D. .................Birthplace... _....................................................... .. Cause of Death............................................................ ___ .___ ............Contributory......___................... __.... __ ..... _... ___ .. _...... .
Date of Death .. D.e.c.emb.er....3.1.,.....l9.5.9........................Hour...................................................................... .. Place of Death..........hom.e........................................ _:..............How Long III 7................................................... .. Physiciall ........ Dr.._... E ......E. ..... ,c:Dani.el....................... Address ..............Ca .s.a:v:ilJ.e .. .. .1 D .........
..;::
Newspaper Notices ............................. _................. ...... Tel ~~phone and Telegraph........................ ..._............. .. Ambulanee ................................................................... . Funer al Coach ............................................................... . Passenger Cars ............................................................ .. ............ Pall Bearers' Service ................................ .............. ...... ............ Transferring Body...................................................... ..
Opening of Grave............................................ .35. ..~..
Occupation of Deceased__.____.......f.arme.r............. _................Social Security No ..........U.O............................. .
Cemet~r y
Name of Emp}oyer........................................... _...._............................................................................... ____ ... __._______ ...... .
Lot .............................................................. '''''''''''''' .... ..
Address .................. ___ ._____.__.................................._....._._.... _...__ ............ _......... _...................................................................
Misc. Trv,nspor tation .................................................... Shipping Charges .................................... ................... . Clergyman .............................................................. ...... ............ Singers $................ Organist $......................................
Charge to....... uI.idOl.t1....ihm1. ... f.& .ml.llf............................_Address ................................................................... Order Given By........ _..!.a.mlly........................................... _...Address ................. _.................. _.... _..................... Date of FuneraL ...........J.a.nua.n.... .l9.5.9................Time......................g..;.3..Q..J'..,.M.,...................... Place of Funeral S.rvice............. _aulll.i~_ !.s....Q.h.a.p.al............................................................................. _. CJergyman .... Re.b. . .... Ab_.. ~ia"'liu.gh... lil~gJL......Call for 7............. :
J .....
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~~:::~o! ::::::::::::::::~:l:. .~:::::::::::::::::: : : : ::
.-
D
.
Interment at... ...........Oak ...Rlll...C.eme.t .e.r.y..: ............................................................................................ .. Lot N o............................................. Section No ............................................ Grave No .............................................. .
i<...ch......guilllle.tal .. .a.nd...J ... tO'D.e....s.1.llr.e.r....lhih.end........
Ramarks ......................s.teel ...
............................................ l?.l..l.t1u.m... JT..e.llLe.t ....inta r .l0.r ......................................................................
FORM
==::::::: ~$.:d-.~.~~:'T~::::::::::::::::::::::::::::::::::::: : :::=::J:Q:::::: ::-~::=::: :::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::: 1i!l.. ::::::
~2 a 5
SUPERIOR FUNERA L S U PPLY COR .... CLEVELAND , OHIO.
Total Amount....... __ ......................... ~119
~
Remains to be shipped-see reverse for details.
............................................ A!;.:hil.n!;.iL..Q.(!..§.K~.~._.Q9...!._.. _.........................
Charges .................................... ....................
............ ............................ ..
o o o o
Lodges
Death Certificate Payment Arranged
~~S.:l:a.~~. j
~ '1 s,-
Informalion Given To: 0 Relatives
Pall Bearers
..;1.5
10 .
0 Clergyman
0 Musicians Attended To:
0 Singers
o
o
Permit Bill Rendered
