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� C.J� �+ <br /> 1�1L� ���1LO11����� �J � JL�1�� ��� �J <br /> 21917—The Augustine Co., County Supplies, Grand Island, Nebr. <br /> � 6(a) Single, widowed, married: d$vpres�.d <br /> i�arried <br /> 6(b) Name of hus�and or wif e <br /> Howard E. Stearns <br /> 6(c) A e of husband or �tif e if a11ve <br /> �l years <br /> 7. Birth date of deceased <br /> March. 13, 190,� <br /> 8. AGE <br /> Years �, Months ,� Days � If less than one day <br /> hr._ min. ___, <br /> 9. Usual Occupation . �io��ew�ife <br />; 10. Industry or business - - - - <br /> 11. Bir�hplace Boulder, Colorado � <br /> FATHER <br /> 12. Name Otto Bullard <br /> 13. Birthplaee Michigan , <br /> MOTHER <br /> 11�. Nlaid�n Name Dora M. Johnson <br /> 15. Birthplace Washin�to�,�'��a <br /> 16. (a) Inf'orma.nt � s own si�nature Howard �. S�earns <br /> (b) Address Roswell, Nevr Mexico <br /> 17. (a Burial <br /> (b Date thereof 1-1.0-�5 <br /> (c Place: burial or cremation Roswell, New Mexico <br /> 18. �a) Signature of funeral direction <br /> Westrum Mor�unary <br /> (b)Address Roswell, New Mexico <br /> (c) Licensed embalmer A. W. �' t�es�� No. lEl-T <br /> lg. (a) 1�athilde S. Urlling 1/9/�� <br /> (Regist��� sSignature) (Date received local registnar) <br /> (a} Was Burial or Removal Permit issued? Yes W.�I.P. <br /> 112 MEDICAL CERTIFICATION <br /> 20. Date of death. <br /> Month January day 6 year 19�5 <br /> hour ll minute 58 P. M. <br /> 21. I hereby certify that I attended the deceased from 1-2-4,� to 1-6-�5; that I last saw <br /> her alive on 1-6-4�5; and that death is s�,id to have occurred on the date and hour <br /> II atated above <br /> Duration <br /> Immediate cause of death Asthma 4� yrs. <br /> Due to - - - <br /> Othee condi.'�ions - - - - <br /> Ma�or findin�.�s� <br /> Of operation - - - Date <br /> Of autopsy None <br /> Where s dise�,se contr�.cted ? <br /> wa <br /> Wa� there an inquest No <br /> 22. If dea,th was due to external cauees, fill ln the following: <br /> (a) Acciden�, suicide, or homicide (specify) <br /> (b Date of oeeurrence <br /> �c Ydhere did in;�ury occur? <br /> �. Did in�ury accur in or about home, on f$rm, induatrial place, in public p�.aee� <br /> While at work? � <br /> (e) Means of in�ury <br /> 23. Signature Cecil W. �u�ek��x M. D. <br /> Addresa 207 W. 3� Roswell, N. Di. Date signed 1-8-�5 <br /> State of New Mexico ) <br /> ss. I hereby certify the with3n and foregoing to be a true and <br /> County of Santa Fe correct eopy of an original certificate f iled with the State <br /> Depar�ment of Public Hea.lth of the State of New Mexico. <br /> Witness my hand and the seal of said Department, this 12 day of Feb. , 19�7. <br /> (SEAL) E. Anne Annson, � .:� ", <br /> Asst. 8�ate Registrax, S�ant�. Fe, New Mexico <br /> Filed for record this 13 day of Febru�.ry 19�F7 at 4:15 o�clock R. H. ,� , A� I <br /> ���� <br /> egl a r oP D- dsw� <br /> -o-o-o-o-o-o-o-o-o-o-o-o-o-o-a-o-o-o-o-o-o-o-o-o-o-a-o-Q-o-a-a-o-6�-�-°`rr��=�=� - =o-a.o- <br />