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CHECK EACH ITEM ,\oS COMPLET
.6.6......_......_...
No•......._ ._......_._ . _ _
Yearly N 0 •. •• _ •. _ ••_ .•
Name. ..._._.................Enl.e.s.t....A.•.. J~;r.Q.c.k ........... _.._.........._.....................................sex. ........Ill§::J,~ ......... Address.............................K§JA.§!?,.!L ..9.J.!;y..,.:..M.t §..~!?1:l.~,1,....................................
. .................................
County ... _.............................._.._...Township....... _........•..._...........................phoii. N 0 •..••••..••.......•...•..••. _ ... ......•.••.. Where Born........Mar!Q......M1.S11.Q.l!.;r.J................. _.._ .... _...........:............... Rac• ..........Y.!J::1.~:!i.~
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.25.•_...1.~a:3.............Age......................25.............................................._.......
n ata of Birth........Q.c.:tQhe.r...
(Y.ars)
(Months)
(Days)
3.... ID.9.nttl.!L............_.................. _...............................................
How Long Re.ident in COmmunity................
Sing l • ........................Marri.d. .. m~;r..rJJ~~idow.d ....................... Divorc.d ...................... Child............................ Hu.band. Wife or Child of....._..........J.e.Q.s.;!.~....\YhJ..?m?JL.! ?.r.Qg.!!:, .................... _.................................. . Addres•............._........ ___...._.._............ _.................. Ki'J.!:H!!?,.§.... g.J.!;.y,.....MJ,!;l.§.().u..~~................................. Clo.est Relative....J--e-e-e.1-e-...B r€Hl-~ ...................................Addr.ss ........................................•......................... Father's Name..........Ir.:v:.1n...Er.Q.c.k. ....................... _.._.....Birthplac•... _......................................................... Moth. r ·s Maiden Nam•....Ma.:r.tha..........................................Birthplac• ... _............................_........................... Caus e of Death.....__........... __ ............. _............................................Contributory___ ..........___ .......................................... Data of Death... _..J.une....4.•....19.5.9...................................Hour .............................. J~.t~:5.
... f.\...,.M.,..........
Place of D.ath...Y..•...A. •... J:!.Q.p..p.J..t.~;L............................. .How Long Ill ? ..............................................._.... Physician .............................................__.....................................__ .... Address .................. _... _........................................... Occupation of Deceased. ...........
fa.r..m.e.:r.. ............. _................Social Security
No ............................................. .
Name of Employer........................................... _... _...................................................................................................... . Address.............................................................................................................................................................................. Charge t o......w.1dWO ................................................................. _.Addr.ss ................................................................... Ord.r Given By ...........wido.w.............................................. _...Address .................................................................. nata of F uneral .......
J_uue ...1.•.....1.95.9.................................Tim• ......................?:..3.9....E'..:.M..~......................
Place of F un. r al S.rvic• ..._.........D.ullT..B.r_!..s....Chap.e.l
Casket ........................ ,... \........................ (Style) (No.) Outside Case or Vault .............................. Embalming Body .................................... ············1Professional Service ............................... . Hair Dresser............................................. . Suit or Dress ........................................... . Shirt, Collar, Tie ..................................... . Shoes ~...................... Hos. $...................... Underclothes ............................................ Door Spray ............................................... . Gloves $.................... Ch.ir. $.................... Flowers $..................P alms $................. . Cremation ................................... _............ . Newspaper N otices ............................. _.. . Telephone and Telegraph. ..................... .. Ambulance ............................................... . Funer al Coach ........................................... . Passenger Cars .......................................... P all Bearers' Service ............................... . Transfe rring Body.................................. .. .. .......... / Opening of Grave...................................... ............ Cemetery Charges ................................... . Lot ............................................................. . Misc. Transportation ............................... . Shipping Charges ................................... . Cler gyman ............................................... . Singers $................ Organist $.................. Cash Advanced ..........................................
....@.
..(l.a l~Jl....T.~........................................
............................................................................._.
Cl.rgyman .... Br.Q.•....K.e.ith... Ma;
[email protected] for? .............................................................._ Addr ess... _......_....C.a.s.s.v..11.le.•....M1..$..(lQ)d.~~...................._._ .......................... _............................ _.. _......_.
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Rem nins to be shipped- see reverse for details.
.l.I.J.J."'",....\J. "jj,' .t>..•,.,".;.,J.......................,..........,............:
Int er ment at...........J:...
Lot No............................................. Section No, .....,.... ,......•..................,.......... G,:ave-'No Ramarks ......................._.. _.............................................................. ,. ... ............~.....-:..~................................................. .
o o
Lodges P all Bearers
o o
Death Certificata Payment Arranged
Musicians Attended To:
OPel Bil:
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Insurance ................................................................... .. F ORM & 2315 SUPERIOR FUN E RAL SUPPLY CORP., CLEVELAND, OHIO .
Date.. ...
..T.unL!±......J...95.2. ..._
(Boone) FUNERAL ·RECORD ·OF Yearly No•... _.......f.1......... _......_...
No...................._____
CHECK EACH ITEM AS OOMPLEl'ED
...@. Casket ........................................................ $.._ ............. Outside Ca~~t!~e~ault......... ~~~:)........... """""'''' ..... . Embalming Body .................................... ................... .
Name....... _......................_......No.e.l ...J..Q.nft.!l............... _.._.......... _.....................................Sex. .......... ~.
