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361 Date. ...NQy.J~.!!!J?.!1.r_ ..
lJ.....J:25 9
CHECK EACH ITEM ~MPLETED
FUNERAL ' RECORD' OF
Casket ~ ... R(l.!L.VI'.o..o..9: ...... .o._~......... .. (Style) (No.) Outside Case or Vault............................ .. Embalming Body ................................... . Professional Service ............................... . Hair Dresser............................................. . Suit or Dress .......................................... .. Shirt, Collar, Tie .................................... ..
'Yearly No •..._.. _.. l2~" .... _......_...
No•... _.. _.._.""._.._ . _ _
Name. ...... _........ _.... _......__ .._.... _M/;\!!)J.~.... I-t.@.~n ...... _.................................................S= ....~.e..m.:!l..~~
......
Address ....""............. "."....."_".,,.,,.E.a.1r.y..;l.e~[., ....M.t.l?.§.9.~.F..L ....."......".. "._" .................."...... "................. County... h
..Nelll.t.O.ll.._"_...Township .....F..r.§,!:lK1Jn....... ".,,..".... Phone No ............................................ .
.""......"."........_"_ ...._...,,"..."".............Race.........~J:1.~.t..e. . Where Born." .."D.ay.:t.Qll*" .. QhJ,Q (
....."................ Date of Birth."" ..J_une....22.."lazQ.. "." ..."...."......... Age.. " ..."""_ ... ".~.3. ............ _.. _............................ _.. "". (Years) (Months) (Days) How Long Resident in COmmunity..........................................._._ ........_............... ____...........__ ._ ... _........ _. ___ .____________ .. . Single....... _.. _..." .." ..Married." ............ "" ... "Widowed..w.ldolll.e.ClDivorced" ....................Child............................ Husband, Wife or Child of" .. "" .. "" .. "" ..... "."."............." ............... _.... " .._"."........."." ...." ... _................................... Address.... """... _".""._"_" __ "_".".. ""._"".".. " .. ",,..,,,, .............." .........."." ........ " ............ " ........" ....... " .... " ............... ". Closest Relativ•._..._.".J.ohn._La.lJ.nuln."""..."".. ".... ".. _.Address" ......... .Q.§,.s..~.Y..:l:}.:l,~J .... J.IlQ..~........" Father's Name"... "_I~c...Miller..... " .... ""." .. ,,_,,_.,, ..Birthplace... _........... " ... ".".. " .. "." .....................,," Mother's Maiden Name"._"~J?J~,n .JIJJ·.Ill~.~.......,,...... ::..Birthplace... _........." ...." .." ...... " ...... " ................... .
Cause of Death0. '--'lC>d~..\l.l1,S...e.!l.Cl......~t..~~~
...................................................
.................. ..... ............wh.1.t.e.... Q.:r.~.p..~ ... J!:l.~.I?.:r..+.-.o..~ .............. ..................................................................
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Lodges D Pall Bearers
Information Relatives D Musicians
D Death Certificate Payment Arranged
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Attended To:
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Clergyman Singers
Permit Bill Rendered
Insurance ......................................................................................... . FORM allsa S UPERIOR FUNERAL S UPPLY CORP •• CLI:VEL:AND , OHIO •
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D.te. .. N.a:ll.e.lllb.e.L.li..... l.9.5 9
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....~
FUNERAL RECORD OF
No........_.. _......_.. _.._.._ _
CHECK EACH ITEM AS COMPLETED
.,
122
a:r.y:....Al::m ...S.ke.l..1i.QIl..............................................Sex..........f..~.!!l\l,.+..~.. Address................... _.. _........ _........ Q§.§.§.y..Ll:.b~.t ....M.1.!?.~g.~.~.~ ................................................................... . Name. ......_...................... _..........
COunty...Bar.ry........._.._.._.._...Townahip....... _.._...._... _...........................Phone N 0 •.•.••..•....••......••...•• _:............. . Where Born.........E.a;r.;r.y.......Q9JJ.!1:t;.Y..,... J!lJ.~.§.9l!,r.J.:
....... _.:...............Race ........... ~~.~.~ .El.....................
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Date of Birth......J.EDld§..r.J....
J.R.•..J:.??.7.9................Age....................~g..............................................._....... (Years)
(Months)
(Days)
How Long Resident in COmmunity..........................................._........... _.................. _.............................................. . Single....... _.._...•.......Married. ....................... Widowed... YI.±9:2!1:.~.~ivorced...................... Child........................... . Husband. Wife or Child of........................................._.................... _........ _............................ _.................._............... Address ......._...._........_.. __._._.... _.._.._............•..................................................... _.................................................... . Closest Relativ•....... .E.lm.er....Bk.e.l:t.an.......................... .Address ..............Q.a!?.~.y...tLl·.lh ...M g.-'........
...c..\!,r.:r.y............................... _.._,....Birthplace•...........:.........•....................................... Mother's Maiden Name... _MaJ:.:i;.Q,IiI....Hg!:ngr...................Birthplace..._...................................... _................. Father's Name....F.!:.~!21s.
Cause of Death......................................................... ~.. _. __. __ ... __.......Contributory__ ._ .. _.................. ___ .. __ ._ ........................ Date of Death... _No.v.emb.er. ... l l •.....l959.................... .Hour...................:j,J.l..3.Q...;P...!.M.~...... _............. Place of Death....Aur.ar...... HQSp.i:tal._........ _.............. .How Long Ill? ............................................... _....
Physician.D.r..•_.A. •....J. ..•....Q.,.....M9.~~.U.W.!L. ................. Address ....~~.r..()E!":.I... ..~I.l,.~ .~.~':l.r..:l: .......... Occupation of Deceased. .........Q,.QY.-.§.l?y!J.f.g ......_................Social Security No ............................................. . Name of Employer..........................................._... _...... _.............................................................................................. . Address................. _.................................................. _....................................................................................................... .
Charge to ........lns\,l~&nQ,tl... .& ... f.&IIlil.y...................... -Address .................................................................. . Order Given By.........f.amily.................. _.........................._...Address ................. _........................ _.................... .
DateofFunel~I. ....... N:Q~r.e:~t!e;~ ...1:i+.c.J,~!~3:.: ............ jr~rr'e... :: .. :~.'.:: .... ~!~~ . 2~~ ...~*:.,~~, ...........:
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Casket
Yearly No .... _......_.. _.......... _.......... .
(Style) (No.) Outside Case or Vault.............................. I.............. 1 ............ Embalming Body .................................... 1...... ......... 1..... . Professional Service ................................ 1............... 1..... . Hair Dresser.............................................. 1••...........• Suit or Dress ............................................ 1............. ··1 ..... . Shirt, Collar, Shoes $...................... Hose $...................... 1••••..•.••..••• 1•.•••• Underclothes Door Spray ................................................. Gloves $.................... Chairs $..._............... 1............ _.1 ...... Flowers $..................Palms , .................. 1............... 1 ...... Cremation ...................................................... 1•.• _....••• •• Newspaper Notices ................................. Telephone and Te:legra~lh ........................... J Ambulance Funeral '"'o:'cn: ............................................. 1 Passenger "a.co ...............................•........... 1....•.. _ ••••• 1..••••• •........... Pall Bearers' SeleYi"e ................................. J ............._. ............ Transferring Du.uY ..............•....... ................• 1 Opening of urav" .................................. _..... 1 Cemetery Lot .................................................................... 1............... 1....•• Misc. Trllnsportation .................................. J. ...... ........ J..... . Shipping Charges ...................................... 1 Clergyman ...... Organist f ............... ··11··.·........ 1.....•
+......
+............. +. .. +......
+...........+.....
To~l Anloun~ .................................. .
Remains to be shipped-see reverse for details.
Interment at....... _ ~j,!'l-@..,a.l.....sprlngs....c.eme.t.e.r.y: ............................................................................... Lot No ............................................. Section No ............................................ G'rave No .............................................. . Ramarks····················g}ot-4.9-} ... ,r.Ucb.e.d ...Q;r>OO1Cl....G.il'\f.e.r ... sl:l&decl .................................. .
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......... . ...................L.:i;... Ji~J3.6.Rn.S.~~~.h~~ §~~.~~.t"~aK:.~~......................... ..........
FORM &2.a8 SUP-UfOJl JF U NER4L 8UPPLY CORP •• CLEVEC\ND , DHIO.
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Information Given To: 0 Relatives 0 Musicians
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Lodges Pall Bearers
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Death Certificate Pavment A rNlnO''''',-t
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Attended To:
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Clergyman Singers
Permit
II R ill R.f>nrlp.l'p.rl
Date. .......N9_y.e.m.R.e.L.l.? ~...195 9
.". . . ,.'"' .
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF
Yearly No ............_............:),,?:L
No........_...•......_.. _..____
...
Casket
Outside cJ~t,;;e~ault {]::f..~".:)............ . Embalming Body ................................... . Professional Service ______.... _............... __... . Hair Dresser... _... __ .__ ..________ ....................... . Suit or Dress .......................... __ ............... . Shirt, Collar, Tie _____.................. __ .. ____ . ____ .. Shoes $...................... Hose $.................... .. Underclothes ...... ________ .__ ..___ .................. _.._
Name. ......_....... Ey..e.r.:t....AUm.aU ...................................................................................... Se:J:.!.~.~;!,~ ............... . Address................... St.s.r.k... C.ity..,.....Mi.s.£l9J.lr.L
.......................:................................................................
COonty .......:Ne,\!!.t.o.n............_ ..TOWllJlhip..................................................PhOIie No ............................................. Wh.re Born..................s.:tark....Gl.tJ[.,.... .M1a.sOl.U'.1... .........................Race.......wh.J.t .!)..........................
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Date of Birth. .......NQy..e.!1l.P..~..
r. ...?J.I....J.9..±.~.......... Age............._.........!±.~ .. _.... _................................ _....... (Years)
(Months)
(Days)
How Long Resident in Community.................. :........................... _........_..........................................._____ .__ .. __ ........... . · I .M • d. roo rr i -.rJ. d D' d Ch'ld S mg ............_.......... arne ......."'..........,...dowe ....................... Ivorce ...................... I .......................... ..
= " 11 Husband. Wite or Child ot.............................. =ma........ IDall......._............................ _................................... S t k C j, t M1 r1
Door Spray .... ____ ............................. _......... . Gloves $.................... Chairs $.................. .. FI $ P I $ owers .................. a ms .................. Cremation ................................................. .
Closest Relatlve._....c.~.de ... All man................................Addr.ss ...s..t .ar.!I;....Q.J:ty..•.;.. MJ .1? §9.lJ.r.;!. Father's Name.........CJ.¥.d.e...Al lman......................... _.....Birthplace..............................................................
Newspaper Notices .................................. I Telephone and Telegraph........................
Address ....... _.... _._..._ .. _.._ ............ _.._...._.................. ~.r.
...............Y..I............f:l.!'lgl\.............................................
.........Birt~ace..........' ................................................... .:.9.~;i...~ ~...........~.:':c;ntribu~~~ 6...... ~3.~.p.. p.Lt.M ·;J~.~. . .:. ..f~;. ...\: ..~ ;l ,' Cause of Death.'&~~:>.. ~ ..•.. :..~.!!.~.~ .......~!t1:,~.1 . . . . c..--.... " 0 Date of Death..·......·No.~mb.er. ... I "'., .... . ....",............Hour,..................... .x . ...... ... .. ....................... Place of Death......5.:t...J .Ohn.!.. S,.".,r.9.;p.l.l.n ..... .MO.., .......HoVi Long Ill ?..................................................... Phyaician ...... Dr.......J .o.e ... CD.ll.1ng .........................."....... Address ... ",.........J.:.Q.P.J.tn. ..... i!41.?·9..CllJ.F..* Occupation of Deceased. .... far.mer....................................... Social Security NO .....~ ....J .:.:: .. C? ....: ...I...~..... ~ Mother's Maiden N ame......,Mo.1l1e.....Ey..e;r.,t.........
~:::s:~. ~=~~~~~~:::::::::: :: : : : : ~:·: : : : : : : : :~: :~: : : ~: : : : : : : : : : :: : ::~:~~~:: :~=:
Charge to..........................................................................................Address ................................................................... Order Given By....f.a m.ily........................................................Address .................................................................. Date of F uneral. ........ ~J.,..ll!-"'J.~~~....................................Time ..................2....P..,..M.,.................................. .. Place of Funeral S.rvice...........stii\.I'k...C1.:ty....
e:tho.dis.t ....Cll:ur...ch.............................................
Clergyman ......... _.............. _.................. _..~.................................... :~~all fox:.?............................_____ .. _______ .______ ............._ Address... _...... _.................................................... _ ......................... ~_...... _............................................... __ .. __ ... _...... _.. _.
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Remains to be shipped-see reverse for details.
Interment at..........D1.c.e...C.eme.t .e.r,y ............................................................................................................... .. Lot No.........................._........... __ .... Seetion No..._____ .. ___............................... Grave No .............................................. . Ramarks .....................
6.J9-....(.J.$....ga.;...........cD.ppe.r.:tOne... n9.....shading ................................., roseh e1ge venus a tin- p ipe organ panel
::::::::::::::::::::::::::::::::::::::::::::s;~:i~fi~:i~LQ.~~.§~.~.~.::·.·Mi.g:~::::Q?::;::::::::::::::::::::::::::::::::::::::: ....... FORM
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aUPERIOR F U NERAL BU"PLY CORP •• CLEVELAND, ·OHIO.
............ Ambulance .............................................. ..
.t:::: : :
Funeral Coach ............................................ . Passenger Cars ____ .... ______........................... . P a11 Bearers ' S ervlce . ......................... __ .... . .. .......... Transferring Body.................................. .. n
• • • • __ • • • •
Opening of Grave..................................... . Cemetery Charges ................................... .
~~:c. ·~;~~~;~~~~;~~::::: : : : : : : : : : : :: : :
Shipping Charges ...... __ ........ _.................. Clergynlan ..................................... . _......... _/ Singers $................ Organist $:
_.......... Cash Adva:c~.i
_......... I .::h..~4/.. .....
=:=::~:::\ :::::::::: ..........
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~64 Date..NQY.~IDJ,).!Zr.._.;G->-.m 9
CHECK EACH ITEM AS C9MPLETED
FUNERAL RECORD OF No•... _..___ .._.._.____
Yearly No ...._.._.. _..
l?!±.._......_...
Name. ...•.. _........_.... _.._.M.inn.1e....Sml.th ............. ~ .._.. _.........._..................................... sex. ..f..~ma.+..e......... Addnlss ................................._.QQmmer.c.a•.... Q.klal.l.9..ma................................................................................ COunty... _.................._.........._.. _...Township....... _........•... _... :.......................Phone No ............................ _.............. .
Where Born............._Ba..cr.y... _C.QUntl".•.....M1.s..§Ql-lt'.;), .... _................. Race....... ~!h.t1;.~.........................
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Date of Birth..ll".lD.-:=.l /3/3.Q ........_............................Ag•............. _.......................................................... _...... . 11-10-1881 Old Am. (Years) (Months) (Days)
How Long Resident in Community...................................... __ ..._. __ ..... __ .................. ___.. __ ........ __ ................................. . Single..........._...........Married. .......................Wldowed ...W.;),Q,9.lY.!'!.!J;livorced...................... Child............................ Husband, Wife or Child 01.....•••...••••..••••..•..•••....••..........•..•...•....•.••... _.•...••. _................................................................. Address....... _...._........ _.._.. __.._...._...... _......................................................................................................................... Closest Relative. __ ...Thalma._.P.aslK\l_1i.y. ........................J..ddress......Qg.~ .~ F..5?!?J.....~_lS.~.?J.l.'?!!!.~
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Father's Name......!l.ez.z...Harher.L........................_.. _..," ..Birlhplace... _............................ _........................... Mother's Maiden Name.......Mar.gar.!'l..t...............................BirthpIace... _........................................................ . Cause of Death................................. _............................................Contributory......................................................... . Date of Death..._..N.9..Y.§IDp..~.r...
.1.:I......:),9.5..9....................Hour............................~.:.. )~.:.............................
Pl.ce of De.th......Q.Q.mm.~r..Q.e.~.... Q.l5,
[email protected]. A'I'rRl1aed
Attended To :
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Clergyman Singers
Permit Bill Rendered
(Boone) Datell!'O.1l.emb.e.r.... 2.1,...~
CHECK EACH ITEM AS OOMPLEI'ED
FUNERAL RECORD QF Yearly No ...._......_1.2.8..... _......_._
Casket ........................................................ $...~ .............
Name.·····.-.·......- ............- .... -....- .....We.l"fie.l"......P..r.\l.J.:tt.............................................. sex......m.a.:Lfl...........
Outside ........... ................... . Embalming Body ...................................................... .. ............ J Professional Service .............................................. .... .. .. .......... J 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 .................................................. .. Tran sferring Body .................................................. ..... . Opening of Grave ........................................................ .. Cemetery Charges ....................................................... . Lot .................................................................................. Misc. Transportation ................................................. _. Shipping Charges .................................................. .... .. Clergyman ................................................ .................. .. Singer s $................ Organist $.................................... .. Cash Advanced ............................................................ ..
No•... _.. _.._...... ____. _
Address ................................._........_.._.... _.F.*ir.:\f.ie.~L7.....Mi.s.so.u.t'.1. ........................................................... COunty... _.Ne.'!!.tO'tl.._......_.._...ToWDship....... _........•..._...........................Phone No ............................_............... Where Born............._.~~..~.~ .?t..~~~.~.~?..::!~ ....._.._...._...........................Race............................................... .
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Date of Birth ..... Ap.I'.;tL.23.•....
J.6.9.3......................Age............•....9..6............................................................ (Years)
(Months)
(Days)
How Long Resident in Community....................................................................... __ .. __. ___ ....................... __ ....... ___ .......... Single........... _...........Married.m"'.r.:r.J51.9. Widowed....................... Divorced...................... Child ........................... . Husband, Wife or Child of....._..................C.r.Y..s.:tal. ...P..ear.l...Da:v..en. .Qr..t ....P.r..ui.t.t .................. Addres•............. _.. _...._.. _..__ .._ ... _.._.._................... F.!i\.J.ry..~.~.w. •...J'(1j,:Ul.Q.liI'.J ........................................... . Closest Relative....... _.................................... _............................. ..Address .................................................................. Father's N ame. ................ _...._............................................_.._.... .Birthplace... _........................................................ . Mother's Maiden Name. ______......................................................__ .Birthplace~ ..______ .__ .. __ ._.... _..................................... Cause of Death ............. _................................................................COntributory.......................................................... Date of Death... _..N.Q.1/:amb.e.r.... 2.1, .....1 9;i.9...................Hour ......................................................................... Place of Death ...... Car.dl!!.e.ll ... liQ.sp.i.tal ..................llow Long III ?.................................................... . Physician .......................................................................................... Address ................................................................. . Occupation of Deceased. .............................................................. Social Security No .............................................. Name of Employer........................................... _........................................................................................................... . Address ............................................................................................................................................................................. . Charge to ....................................................................................... _Address............................................. _.................... Order Given By......................................................................... _...Address ..................................................................
Date of Funeral... ....b!o:\f.emb.e.r. ... 2,p.T.... l
9.;;.fi!................Time ...............2..l' ... !.L•.......................................
Place of Funeral Service....... Mc.Q,u.e.e.n.!..Il.._Gha:p.al......................:.......................................................... -. Clergyman
[email protected]..•.....I ..r_.L •....)'3..e.;r.yJ.Q.e..§ ...................
Ca~:~;etault ,&r~:)............
Name. ..................................V/..l.lliam ... D......Br.o.vm ....................................................... sex. ......mab.e...........
Outside
Address ........................... .l.l.Q.Q..J!la.l.n... S.:t.l:e.§:t..,........... Q.MElY.U.1.f?,.....MJfl.~,'?.!:!.:.::;\......................
Embalming Body ._____ ................ __..___ ._____ . Professional Service .............. __ ............... .
County...... B.ar.r.y.......................Township ................._................................Phone No ............................................ . Where BOnL............Gr.!UillJlJ,l,J,§.,.....
::::::::::::1~:i~ o~r;;::s:·:::::::::::::::::: ::::::::::::::::::::::::::
U..Ur.t.l .... ~.:l,~.s.c::.~.J:::l:
........
Father's Nam•......J ..•. _.R-.._.E.s.s.ar.y........................._.. _.....Birthplace... _........................................................ . Mother's Maiden Name...-Mildr.ed ... B.r.ans.:t.e.:t.t .e .lJlirthplace. .. _......................................................... Cause of Death......__ .......__................ _............................................Contributory___......... ___...........................................
J.9..5.9. ...............Hour........... ~ ..........6...l'..ll..........._.....................
_..........
Place of Death...B-l.;\,fl-ll...Ha:v:.en...Re.s.t ... Hom.e........ lIow Long Ill? ..................................................... Physician ..................................... __................................................... Address .................................................................. .
............
Dat. of Death..._..... NQy..fl.mP..~.r.... g.7..'---..
Occupation of Deceased............................................................... Social Security No ............................................. . Name of Employer........................................... _.............................................:............................................................. . Address ............................................................................................................................................................................. .
Charg. to............. G-er.tle....EdlNar.u.S............................. _.Address·············J€fl-ll;,ins.j··.· ~;j,&-llG.Uv..l Order Given By........ G.g.r.tlfl ... EQ,~I.ar.Q..!L ................. _...Address............ .J~nkinl>,.... Mis.£D.uri Date of FuneraL.. N.o.:v..ernb.er.... .).Q.~ ... J.95.9. ..................Time ...................... :P...~.lI!.: Place of Funeral Service... _...J .Qn.e.S....Q.c_b.QQ1 ..HQ~.§.~.........................................................................._. Clergyman ......... _.............. __ ................ _.........................................Ca11 for? ................................................................
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rofessional Service Dresser. suit or Dress ............................................ shirt, Collar, Tie. shoes ~......._.............Hose ~ U nderclothes D oor Spray Gloves $.................... Chairs !l. F lowers $.................. Palms s. Crarnation N ewspaper Notices elephone and A mbulance ... Funeral Coach . P assenger Cl Pall Bearers' .. . Tr ansferring Bodv_ Opening of r., Cemetery L ot .. .................. ,;, Mi::;c. Shipping Charges Clergyman Singers $................ Organist $. Cash A
............,T ............ ............
................................
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outside Case
Wher. Born............._.......8.:to.n.e__C.o.unty.•..J,U.a:e.Q),l.r..:!,.................Race ..........1Yl})..~.~......................
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Name._._._........_............_........__ .M.1nnl~....~.~lJ...A§h.~.~.......;................................. s.-,... female ........ . COunty.....laYl.r:e.n.QJL .._.. _...Township......._............_...........................Phone N 0 •. ••••... •......•. ...•...... _ .•...... . .....•
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.............. I···..· I··:···
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Total Remains to be shipped-see reverse for details.
Interment Lot No ............................................. Section No ..............._............................ Grave
..........................................yi.Uit..fl.....(lB.t .ln.. J,y!.;\..U ....±D.~.~.r..~.().:r:............ .............. ..... ........................ ...............: ................ J?!?!.!::Y!.0.;_...Q.?:.~):c.e..E. ...R~.€\.:....g.~..:..................................................................
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Lodges D Pall Bearers
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FORM l5.2 l!1l1 SUPERIOR FUNERAL SUPPLY CORP. , CLEYELAND, OHIO.
Death Certificate Payment Arran~ed
I
1m
/
Information Given To: Relatives Musicians
o o
Attended To:
o
o o o
Clergyman Singers
Permit Bill Rendered
371 Data ......
QY..elub.e r.__3.Q._..l959 FUNERAL RECORD OF '
CHECK EACH ITEM AS COMPLETED
Yearly
No•......._.._......_.._____
No_ .._..... l}l ......._......_...
Name. .._.._.................._.. __ ..NaIlQy.....L.1.fl.a ... Q.r.:r.... _..................................................... Sex. ........ .f.\1m.a.~.:J,. Address ....... __ ...................... _.....J.e.nkina.~ .. J 1a.SQ.ll.r..l................................................................................ COunty......Bar.r.y....._.._.._.._... Township ......._....MQIl.Q.nal.Q, ...........Phone No ............................................. Where Born..........~.I?;;:.rX....Q2.ldny.y..,.....M.~.§..i?.Q),1.J'. L................~ .........Race...............,~!:t.~.t..f:'.
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Casket ..............................................................~ (Style) (No.) Outside Case or Vault................................................. . Embalming Body .................................... ................... . · ........ · .. 1 Professional Service ................................................... .
:::::::::::1~:i~ o~r~s::~.::::::::::::::::::::::::::::::::::::::: :::: :::::::::::::: ::::::
Date of Birth. .....N.Q .y..elUh"r....J.Q.......J9.59.......... .. Age...........................................................?.h2.ldF..i?.. . (Year s) (Months) (Days)
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 .......................................... .................. ..
How Long Resident in Community.............................................. _............:..: ......... __..____ .................... __ .. _...... __ .... __ .... .
Single........................Married........................ Widowed....................... Divorced...................... Child .....ch11d ....... Husband, Wife or Child of................................Haz.el.. D.rx............................................................................... Address ............._........_.. ____.. _...._.. _.._.............•.........o!...~!.1:!t.~~.§., M.*'~ s.~y!'.~ ..........................................
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Closest Relative......._........... __................................................:.. __.Address ...... ____.............................. _....................... .
Father's Name............._._.... _.............................. :: ........... :_._: ....Birthplace... _........................................................ . Mother's Maiden Name.. _____ .........................................................Birthplace.~.:. .................. _.................................... . Cause of Death............._................................................................ContiibutOry..~ ...................................................... . Date of Death...........No.v..Elmher.....ll.,.....195.9...........:.. .Hour...................ll...l'... • ............................... Place of Death...... hQme....................................~·. :.:.:~~~ ..........·... .How Long III ? ..................................................... Physici.n ...........Dr.•.... E •....E.....
c.Dan.lf:.l.................... Address ... .Q.a.§.§.YJ.1)..~.•.....Ml .1Hl.9..\.!.r.: t
Occupation of Deceased. ............................................ _................ Social Security No .............................................. Nanle of Employer........................................... _............................................................................................................ Address ..................................................................... _.......................................................................................................
Charge to.......... Ml'.•....& .. .Mr..g.•....W1.1.s.on .. D.r.r.............Address ..........J .enkina •....M1 a.s.our1 .. Order Given By..............................................................................Address................. _............................................. ..
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Date of Funeral.....De.Q.Il.mb_e.+:'.....L .....19.5.9......................Time...................? .. M -'... ................................ Place of Funeral Serviee....:........ _.................. _........... _.. _................................ ;..:.................................................... _. Clergyman........ R~¥.•....Lo=...:s:all-l.e¥..........:.............. Call for? ................................................................ 1" 1 ......... ,. _. .11 Address..........._.............. &-8.8.11.1 IIe •.... _"-'-a.sO'll.r.
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Remains to be shipped-see reverse for details.
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Lot No ............................................. Section No ........ :...... ~ ........................ \ Ramarks ....................... _,;-'....p.Jn~........~."'.:!:1I:
... p.:I:1:l.~J.t.............. ... ......... ............................p.J!lt....Cl.F.~.l?.~... JD.~.~.:r.J.'?.:r.......:...........I., .......................................~.~.~::".y~9.:;J.-... .9.§:.§.~~.t.....g.!?.l............. _.........!
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Total Amount. ................................. I- - -1
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Interment at................._.....O.ak ...~e ....c.8m.e.t.ery............\
FORM 1523 " SUPERIOR FUNERAl. SUPPl.Y CORP .. Cl.EVELAND , OHIO.
==::=:::\ ::::::::::::::::::::::.::::::::::::::::::::::::::::::::::::::::::: Information Given To: Relatives o Musicians
o o
Lodges Pall Bearers
o o
Death Certificate Payment Arrang'ed
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Attended To:
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Clergyman Singers
Permit Bill Rendered
Insurance......................................................................................... .
