) STATE OF KANSAS STANDARD D o COt WTltO

State Board of Health—Division or Vital Statistics CERTIFICATE OF DEATH

1. PLACE OF DEATH: Comiy....Ui<<X.i2'/.e<£.-zZ££K>L,
63 4^5*
In l l i l i i p a c s
Township _,.-= ^-.-.. _ Rern'stered No....».~*...«.... 2 S.,; tr?..i...
City. £&^kZZ^*&3& W«- •&/<> , / / ^J+Sl^O^ZA St, „.Ward
J~si [1 /? jX» /^P ( I f d e a t h occurred in t. hospital o r institution, j i v e i t s N A M E instead o f »treet «nd number.)

FULL MAMB ^ m ^ r J c ^ ^ o ^ ^ c ^ ^ ^ ^ ^ ^ QA+J& <••;f:•« - > v ^ - ' • ' - ;

(a) Residence, Xo~Aj.£I...^&tt^...^t^^/Z^£s. St, Ward ......
(CmiflJ pluce. of abode.)
plG.cn o: ( I f nonresident, give city or town and state.)
L e n g t h of residence in city or t o w n w h e r e d e a t h occurred. i&f£ yrs _.mu» d». H o w l u n g I n U . S . , If o f f o r eihrn
ign bbfi r t h ? yrs tnos da.

T r a s d e c e a s e d n v c r a r a c m b e r o f tlm A r m y , IVaTy, o r U u r l c o C o r p s o f t h e C n l t e d S t a t e s ? . .

I f s o . R&ttte Orjciir.Uutlon.. EcnJc I'crlod o f Mrvlce..

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH

3. HEX, 1. COI.OB Olt K A C E S. S i n g l e , S l u r r i e d , W i d o w e d , 21. D A T E OF D E A T H (month, doy. a . J year) / / " " i - l» J 1 -
or Divorced (write tho word)
<ji->
i OMrrteu.
J±L
iWCy, OV Ot^CrCC*!.
22. _ I H K E E B Y CERTIFY. That I attended deceased
Q..!&!..._.04 wa2?^__,3rf3r3L3: _ !!>..>..?
from

mmossa I lu»t s a w h^uY.-ttHve o n bJk£.*X?5\...r?. , 1 D 3 ^ ? d e a t h IN «ald

(or) w i n * * Si"*
to h a v e o c c u r r e d o n t l : s d a t e s t a t e d a b o v e at.^.if iu.
l>ATK O F g a g j j g ( m o n t h , d n y . a n d y o u r ) /g'S'/ — J) - ff^SL T h e p r i n c i p a l e m w a o f d e a t h a n d r e l a t e d c r a n e s o f l m p o r t a n c « In_order
of o n x f t i r e r e a » f o l l o w s : Ozio ot onset
A OK S*fl*J Duy» If L E S S tliun
1 day, hrs.

3. Ts -vie, proXaaion, or particular

31 /
g or— mln.
..0|535^^rEiSSS^!*rI™.
kind of work done, ru ns>l»i»er* j L&e,i^-sr*t
x
s a w y e r , b o o k k e e p e r , etc
C. Industry or business in which
work war. dorse, EIS s i l k m i l l ,
sa.iT m i l l , b a n k , e t c _ , C o n t r i b u t o r y c a u s e s ot i m p o r t a n c e n o t r e l a t e d t o p r i n c i p a l
caune:
10. xj_te dec«-As«l last worked a t 11. Total t i m e (years)
t h i s ocGapatSoQ ( m o n t h and Spent in t h i j
year) / . . . . # . . 4..M. occunaticn.—.......

12. B H t T n r i - A C K (city o r t o w i
(State or country) tn )f/i:t^7rt^.U^fyy....:.
Xarnw o f o p e r a t i o n .T. JJ. Date o f

i*.
AMB ^rg* >r„ y _^ g... ^/ ra.Lf «- / r
w r R T i r r i . . - i c K Cctty o r t o w n ) . . .
W h a t l e n t c o n f i r m e d 0l-:jHGrUs?.V.^^Llrfr7Vrni) tlicr« a n a u t o p a y T
23. I f d e a t h wan d u e to e x t e r n a l eau»t f J (vlol«nc^> fill l a a l s o t h e f o l -
( S i u t o or c o u n t r y ) laxvlnir: v ^—^_ ._—»
A c c i d e n t , bulcide, o r h o m i c i d e ? l i s to o * I n j u r y ID
IS. MAIDEN X A 3 E " ^ t - C ? ^ ^ j f ^ g g 3 ^ " g i ^ a 6 j g 5 l i g ^Viiero d i d I n j u r j ' o c c u r ? _ _ _
(Specify city or t o w a , county, and a i s t c )
10. M X t T I U ' E A C E ( c i t y o r taiYn) SSkSB Pper'<y w h e t h e r I n j u r y o c c u r r e d In I n d u s t r y , in h o m e , o r In p n b l l o
(Stale cr country) " pluce.

17. i N r o K a A N T , . ^ ^ ^ , . i l . ^ . 2 ^ ' 1 & W^ M a n n e r o f Injury..

43ns~JZc£x:t4--
N a t u r * o f Injury..
19«5-^* 2-4. \ y e « d i s e a s e o r I n j u r y I n a n y w a y r e l a t e d t o o c c u p a t i o n o f d e -
'^<Z<£^£2^ ceased ? r!7fr^rr-rij!?..^^
13, P K ^ l ^ n S A K X K ^ f e s ^ ^ ^ U ^ ^ ^ ^ ,
3f s o . s p e c i f y — HUM - Jh — -

so. FILED../.:.;..,r,::..f ^„i»s32, £jfefe^Jli^!li£r5==! (Addro..) Qu^.^A>^^.0rl<C. t ..l'(4..../

licpiMtrar.

hf J Y *'
 FEB 1593

NOT VAUD IF COPIE»

U n n - i f B Ota OATf AT TOjfJt*. f.*>i3AS_.

llfMIll
5TA1I.V,
• r OF Mi .n. A«DO«it;-3ai*aiT
 V* STATE OF KANSAS STANDARD D o not write
State Board of Health—Division of Vital Statistics CERTIFICATE OF DEATH
L PLACE OF DEATH: County..
W3 4^5*
In t his s p a c e
Township „ , Registered No, htt-L&U..
or
City- m i^» /^P
}M&l<bM
JXt
_St,„.
death occurred in a hospital or institution, give i U N A M E instead of street and number.)
Ward

FULL NAME.
(a) Residence. No^.../?X....^UK ii St, .Ward :.
(Usual place of abode.) *~r*~ W nonresident, rive city or town and state.)
L e n g t h of r e s i d e n c e In c i t y or t o w n w h e r e d e a t h o c o n r r e d . r a . y r s mo» da. H o w l o n g In V. B., If o f f o r e i g n blrthT... *.....—moe.... da.
W a a d e c e a s e d e v e r a m e m b e r of t h e A r m y , N a v y , o r M a r i n o Corps of t h e U n i t e d S t a t e s * — —
I f s o . s t a t e Onranlzatlon.. Rank... P e r i o d o f service..

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH

4. COLOR O i l RACK | 0. S i n g l e . Married. W i d o w e d , tl. D A T E O F D E A T H ( m o n t h , d a y . » » J r e a r ) / f— X- , 19 J i—
or Divorced {write t h e word)
M. _ I HEREBY CERTIFT, That I attended d from
QXAc^fy% i932r *,.._, It..?....,'
I l a s t s a w b A j f L a l l v e on_...Kj>iCvmi!r.v.....^. , l » i ^ ? dealth Is s a i d
(or) W I F E of bMb&&4£z?Z%&i&&. t o h a v e occurred o n t h e d a t e s t a t e d a b o v e atsSJ.f_.rn.
D A T E o r 15 ( m o n t h , d a y , a n d y e a r ) /frS"/ — J) - J-'f T h e principal c a u s e of d e a t h a n d r e l a t e d c a u s e s of I m p o r t a n c e in order
Months Days If L E S S t h a n of o n s e t w e r e a s f o l l o w s : I Date of onset
1 day,.„.—hra.
or... mln.
36-3,1
8. Tj-;de, profession, or particular %
kind of work done, as spinner, y iJ*rj^*t
s a w y e r , bookkeeper, etc " *^
9 , Industry or business io which
work was done, as s i l k m i l l
s a w m i l l , b a n k . etc. Contributory c a u s e s of Importance not r e l a t e d t o principal
cause:
10. C^te deceased last worked at 1 1 . Total time (years)
this occupation (month and spent in this
year).. occupation. ......

1*. B r B T H P L A C E ( c i t y or t o w n ) lfak£tt3<&..
( S t a t e or count:
country)

13.

U.
NAME
^Z2
BIBTIITI.ACF. (city or town)..
N a m e of operation.
W h a t t e s t confirmed d i a g n o s i s ?
23. If d e a t h w a s d o e t o e x t e r n a l c a n *
D a t e of. „
a» there a n antonsyT-fe^rl?...
(violence) Oil l a a l s o t h e f o l -
( S t a t e Or c o u n t r y ) lowing*: ,
A c c i d e n t , suicide, or h o m i c i d e ? . . . D a t e o f Injury , 19
15. MAIDEN NAME
aaaamy. W h e r e d i d Injury occnrT
(opeciiy city or town, county, and state)
18. B I R T H P L A C E ( c i t y oorr tcjfYnn S p e c i f y w h e t h e r Injury occurred In Industry, In h o m e , o r In public
( S t a t e or c o u n t r y ) pluce.
INFORMANT,-,..
(Address)/J/£ , M a n n e r of Injury..
N a t u r e of Injury..
BURIAL. H--01S I t M J O T l M .
Place ' *<%$&£. / / - / " .»3: tt. W a s d i s e a s e or i n j u r y i n a n y w a y r e l a t e d t o occupation of d e -
ceased T _ _ . ! 3 _ - * r * 2 . _ _ _ _ _ ^ ^
TJNDKBTAKEBJ
(Address) 'SSfJ I f s o , specify _...

rnxo.2.L^~.i...^..^..\9^J2, ..._Z!~& (Signed) .CyV^..<.L<.. . •_V_3i Jf. D.

~f ReQtotrar. (Address) Q»-rV«„

MS. 4£~~f>
 FEB 2 1393

NOT VAUD IF COPIED

» K 3 IS A C O M Ol THE OfWIHAl. CIV11 .TCATg
d f l T I f * B THIS GATE AT TOPCIU. KANSAS^

FMTM
y=V**«
»»ATI3V1C-. «TA1K ftCOlSJIUH
ae?.n»'. MTOFHi -. .TK AJwoJV:r:am.""jiT