Pall Bearers' Service ............................... . .. t" H ' t 1 ........... . PI.ce of De.th . ..... Pall Bearers'
122 Date.... NQ.Y..erob.e.r.:...}.•.
_.12.9.0
.
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF Yearly No.... _.. _.._..122... _...... _...
No........ _.._.._.. _.._ _ _
Cask.t ............................................................ (No.)
N ame. ...... _.......................... Y..~lm.~...!?~.g/?.~....K..~J~x....................................................Sex............re..lll1l:~.e.
1'- ........... 1.....
Address................................. _...Eo.rm.a...Q1.ty ..... .QI(!,iWg.!!!~.................................................................:..... County...........KaY................_.. _... Township......._.. _..................................... Phone No ........................................... .. Where Born............._...__... _..._...._................_.........._.. J ;dlB..§9_\!,;rJ,........Race... Wh.;h1;..~........................... ..
(
Date of Birth. ........WgUs..t..2.1.~
.....l9..Ql.................Age.....................5.9........................................................ (Years)
(Months)
(Days)
How Long Resident in Community...... __ ........J}.._¥-..e.:?vr.S ...__ .......... _....................... _............... ___ ............. _......__ .. . Singl............ _..........Jllarriedl!laI'.r.1£l.d . Widowed....................... Divorced...................... Child........................... . Husband, Wil. or Child oL ..................... Ear.l...K.e.lly..................................................................................... Address ......................._.. _...._........ _...... _........P..o.nc.a....Q.1.t.y....... Qk,AiWg.!!!il................................................. Closest Relativ.....Mr..s...... B.A....T......MilJ..ik1n.............Address ............HQ~.!?y2g, ... ,1'.!'i.~§\.~......... Father's Name......:r.ohn.. Black............................... _.. _....lIirtllplace.............................................................. Mother's Maid.n N ame.......
F.19..r.~ ..........................................Birthplace..:...........................................................
Cause of D.ath....ACl.ut.e. ...Q.Qr.O.na.r.Y.....Tb.;rQm.R.Q.J?~oiltributory ........................................................ .. Date of Death ......... NQ.y.e.mb.er. ...}.. ....19..6.Q...................Hour........................................................................ Place of Death ............................................................................... .How Long Ill? .................................................... . Physician...........................___.....__ ..................... __ .. __.......................... Address. __ .__ ..............._.... ___ .. ______ ............................ . Occupation of Deceased. .............................................................. Social Security No ...... __ .... _..................... _..._...... . Name of Employer........................._.......... __ ..... _.............................................................. __ .... ____ .................. _................. Address ..................................... __ ........................._.... _..................................................................................................... .. Charge to................................. _................................................. __ ._Address ............................................. _.................... Order Given By......................................................................... _...Address ................._.............................................. . Date of FuneraL .......N.O.1T.e.mb.e.r.....6......1.9.6.Q................Time .....................
? .J'....M....................................
Professional Service ................................ H~ Dre.sseI: .............................................. Suit 0 1' Dress ... ............................................. 1.............. 1.... . Shirt, Collar, 'ri.e........................................................ 1.... . Shoes $...................... Hose ~ ........................ I............. Underclothes Door Spray .................................................... 1 ............ . •....·.. ·.... 1Gloves $.................... Chairs ~.................... 1.............. Flowers $..................Palms Cremation ..................................................... 1........ ..... . Newspap er Notices ................................... 1............. . .. ........... 1 Telephone and T"lelrraph .........................I........... .. Ambulance ............. 1 Funeral U c'ac.n..................................... ........... I............. .. ........... .1 Passenger .!? ......Birthplace............. ·····························l ·····::t:······ Cause of Death.. ..l~(..~ Contributory.(,!..e..~.~g.".l!.v..~ .J.~(.L ..
R
..
t" H 't 1 n.J..C...• Q.•~;p......."L..............How
Long Ill? ................................................... ..
Physician..........Dr .......G._....H. .....J.Qhns.Q.n .......:................. Address ......... Q.i3,.El.fl.yJ1..;J,.~ .,.....M.1..~.El.Cl.\;:r.l Occupation of Deceased.. __ ..... hG~~. g.€-l;,l.i.:t'. €- ......................... Social Security No .............................................. Name of Employer ........................................... _... _...................................................................................................... . Address ............................................................................................................................................................................ .. Charg. to..... J;h.1.1d.:r..e.IL ..................................................... _.Address ................................................................... Order Given By.....................Qh.t11.r...:lL.............................Address ..................................................................
Date of Funeral... ...... .N.Q.y..e.m'Qf:.;r.....;U~.... J.9..Q.Q............Time ............? ...f
.,.AlL ..........................................
Plnce of F uneral Service..............Ro.ar..1ng...E.1.v.~.:r.....B..p.J2.1;.;l,.§.1;....~.b-.1.,lT.Cl.l1.:::.~.?$1..~....F.t9.c::..~... Clergyman........Ed..i.fj._E.'"~lelf..~..Be=e.t .t...................C~1l for? .............................. :.............................. _
(
D
~~!t~~;~S:~·;i~:::.::.: : : : ··: ·:·: .: : : :·:· : :
Shoes $......................Hos. $...................... . Underclothes ........................................... . Door Spray .............................................. .. Gloves $.................... Ch.irs $1t.~ 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 ......................................... .
I ............
L..h?e,Y.I.C).\.. ..E,a. ............. . EIf, "D.te of Death... N9.y..~m1?~.r..... :z~. ...:L.2.§9........................ .Hour .....................} ... A •....M.............................. PI.ce of De.th .. D.S....e.O.pa
JJ.~~~~~)~ ..
!
==::::: :1:::::.::::::::::::::::::::::::::::::::::::::::::::::::::::::: _ ··..··· 1··············································....................... . Total Amount.................................. 1
' -
'1 -
Remains to be shipped-see reverse for details.
Inoormentat.......Jll~nQs)y. __ ~.~J.P.~~£~;r.;Y..........................~
o
Bearers
Lot No ............................................. Section No ............................................ Grave Ramarks ...............R.:r.9A.19,....(lh.a.1.e.g, ....§JJ:v.?.r..... P.~.J:'.f..~g.!:..~.().I?: ..................................................... .
.................................lIlh.l.t.~....Q.r.~p..~.....1."'J..t\?r..±Q.r..... .Y!.:1:.~J:l.... c.>.r..()J:l.:i.
