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<br /> . 37Z� CLQAP4HARTLETTCO..PRlNTING�LITNOOHAPHING�STATIONEqY�QMpHA . � . . . . . -_._._., ___ __
<br />__ ��_�- _ -. _.�:�_. . . . .. . .. . . . . . . . .... .-.-.-- .--- .__.�-.
<br /> ,__ ..: .. ��.:._ .:�.. .. _
<br /> � � 1. Place aP Death State oP Illinois
<br /> �� � � County Peoria „` State Board of Healtri_-yBureau of Vital Statistics
<br /> �+ b � � TownBhip or Re i�tra n Standard
<br /> a� � o� � Road Diet. �' , Di�t.No. 7�+7 C�rtiPicate oP Death
<br /> � � o� � or Primar�,y Registered No.l�: ,
<br /> a+ � � Incorp. Town Dist. o. --
<br />� ° �� �� � °r vorlage t t�s�iia�'1 o�tenediiu a
<br /> �,� .a o� � e ��estreet��an�
<br /> �� � City. Peoria. _No. Proctor Home St. ; _ Ward ����r.�
<br />! c°� ,� o � � .
<br /> „ U � ��,.; , 2. Full Name Etta M.�torris.
<br /> U � � U� � --
<br /> a� mt� � H — — — — — — — — — — — — — — — — — — — — — —�__— ___ —_ ' �_ — —__ — —__ —=
<br /> � a-� G°., �a��a �� Personal and Statistical Paxtieulars � Medical CertiPi�ate oP Death
<br /> � � ° � � s 3.Sex �+.Color or Race 5.Sin e 16.Date of Death
<br /> +� � �o Female White �a�'��eg� ��in�le ) J�.nuar 1 , 1 17.
<br /> a`�i' �-o � �w i� . ord��vo�ced (�tonth�) (�aY ) �Year )
<br /> a � �,� w,� �
<br /> �, �,� �� � . Date of Birth • I Hereby CertiPy That I atte,nd-»
<br /> a, � � �,��, � , 1 ed deceased from Jan.l�',1917,to Jan.lq
<br /> � � � � � � on ay ear 1917,tnat I last saw h-- alive on 10:30
<br /> � � � �' v"� � 7.Age If LESS than P• •Jan.19,191-,and triat death occurec�
<br /> �+ � � � 57 yrs. ---mos.--ds. 1 day,---hrs. on tne date stated above�,at -----m.
<br /> o u� o �a � or ---- min.Y Trie Cause oP Death� was as follt��s:
<br />' c '� a�-+''� � - - - Pneumonia Broncriial Asthma
<br /> x � m � S.Occupation
<br /> � � � (Duration) --yrs. mos.,_,,,,ds.
<br /> � � .� �, � (a} T�ade proPesaion or Contributor
<br /> � :� � i partieular kind o�` work - - - -
<br /> a, ; � � � � i (b ) General nature of industry, (Seco�.dary�
<br /> a +� u� �� � bu iness or est� blisnment i (Duratian) --yrs.mos.",ds.
<br /> � � � � � � wri�en em�5loyed,�or employer�`�
<br /> � � � �� � (Sfgned T.J.V�riit�en �. .
<br /> A, .� �+ c�� � 9. B r h lace (Address
<br /> � y Date 1�20 19--. Tele hone�
<br /> ° �' � �H � Sta e flr Countr Ill. . , p
<br /> � �
<br /> ,� � � o,� � � � lO.Name oP Father John . o�x�s .Leng ri o Res ence �'or osp a s,
<br /> 22,�31rt�}piaee oP �atner Institutiona,Transients,or Recent
<br /> � ,.
<br /> a y,c� �,� � � �' ( State of country ) I11. Residents )
<br /> ,,, �, � ,� ,� � m At place of death 1 yrs. 2 mos.--ds,
<br /> 1�.Maiden Name of Motrier Kate ScnancK In tne State ------ yrs. - mos.--ds�
<br /> � � �T'� ,�, � a 13.Birthplace of' Mother Where was disease contPacted, if not
<br /> � � w � �- i State or countr - - - - -
<br /> v o �� ,-� at place oP eleatri?-------------
<br /> .,� � � 1 . The Above is True to trie Best of �.y Former �r usual residence
<br /> p� � � � � � Knowle age
<br /> Proctor Hom
<br /> mc� o � � �
<br /> (Informant ) E. S.�dillard
<br /> � � �� m i 19.P1a e oP Burial Da"t� a� _Burial
<br /> x � � � f (Addre�s } �lilliamsfield wi�����field Y1L Jan.24,1917.
<br /> H �'' �"'' � � 15• Filed Jan.2p,1917. '
<br /> o � a ddress
<br /> ' E.Ricnarcls�n, . . . . . . . .Registrax 2�•Undertaker IIA
<br /> � - - E. . 111ard Wil iamafield I11.
<br /> �'orm � � a e e sease aus ng ea or, n ea s rom o n auses,s a eans o
<br /> �. S.i�o.�� �_ In�ury; an.d (2 ) whether Acciden�al, Sui�cicl•al, or Hamicid8l_ _ _ _ _ _ _ _ _ _ _.
<br /> � - - - - - - - - - - - - - - - -
<br /> ' Filed Por record tne �+ day of September, 1917, at 10 0•clock A.�.
<br /> k ��. ,�/ �j
<br /> �.���l V-'� ._.,.....
<br /> Register of De s.
<br /> � -1—�-4-0-0-0-0-0-0-0-0-0-0-0-0—�^-U-4—O-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0—O—O—fl-0—O-0-4-0-0-0±-
<br /> ;;���2:--
<br /> 5rielton, NebrasKa,
<br /> August 29tn, 1917.
<br />� ��or and in consideration of One Dollar (�1,00 ),trie undersigned bank agrees to accept the pay-
<br /> ment on March lst 1915 of a certain note an� mortgage on tne North Hal�' oP the S�utheast Quaxter '
<br /> (N.� of S.E.� �, and the South Half of th� �Northeast Quarter (S.� of N. E.� )� of Section Number
<br /> � Sev en (7 ), Township Number Ten (10 ) West, Ran�e Number Twelve (12 ), North of trie Sixtri P.M. , Hall
<br />� ,
<br /> Count�r, Nebraska; the same being executed by Lawrenee H. Cox and Rosa A. Cox, husband and �riPe to �
<br />� 2�eisner•s Bank, at Srielton, ;Nebraska, on April 14th, 1917, wriicri is recorded in BooK No. 47 of
<br />�
<br /> � � Mortga�es, at Page �I$2 , in Hall County, Nebraska; said note and mortgage being for trie sum oY
<br />� . ' Eight Thousand Dollars (�g,000.00 )
<br />' • Tne intention here�f bein� that said note �.nd mortgage, plus tne interest due tnereon, may bQ
<br /> pai d on R�aren lst, 191g, at the oFt ion oP sai d I,awrence H. Cox, or the owner of tne property on
<br /> ' which said mortga�e was �iven, if said property is sold by said Zawrence H. Cox, even tnou�ri the
<br /> ��I-
<br /> `� ' > said rnortgage does not contain an optional payment clause.
<br /> ' ' (CORP ) �Ieisner•s Bank. of Shelton, Nebr
<br /> �SEAL ) By. . . . . Geo.w.Smitn. . . . .Casnier.
<br /> Filed. for record trie 6 day of Sept�ber, 1917, at 3:30 o'clock P.�., �f
<br /> �>-�����-uE ��/-��y� ':
<br /> Regi�ter of Dee�s.� � ,
<br /> —O—O—O—O-n 0-4-0-0-0-0-0-4-4-0-0-4-0-0-0-0—O—U-0-4-0—U—O—O-0-0-0-0-0-0-0-0-0-0-0-4-0-0-0-0�-0-00-0—;
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