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b. clTr (u sodas <nrparaa lime e, ebr, Hall
<br />write Rnrd) LENGTH OF (
<br />OR c. CITY If
<br />outside corporates limite, write RURAL)
<br />I ". OR
<br />tS TOWN -r —' Tc l ^., rl
<br />i d FULL
<br />NAME — 11t not �o hnsp�tal or
<br />L O ft rur
<br />d. STRRET (If al, glue location)
<br />HOSPITA on A 11 - ADDRESS
<br />X INSTITUTION u�4 'PS Sta t2 Ho$C)
<br />^l'� Tj.,.. ..ry i af, ctT.o.�l•,
<br />-
<br />8 3. NAME OF c. (Ftr t - -- �-� - -- - -- - - - --
<br />n DECEASED .) b. (Middle) e. (Lest) d. DATE (Month) (Day) (Year)
<br />(Type or Print) Tlr -„-(r
<br />FR La -c� DEATH •'illy 97 14K
<br />I
<br />S. SEX:
<br />I
<br />h le
<br />6. COLOR or RACE
<br />, t
<br />7h_ e
<br />7. MARRIED, NEVER MARRIED 8 llATE OF BIRTH
<br />I WIDOWEll DIVORCED (Spec) {y)
<br />?':arried arch 37 1?83
<br />9. Age (In yra I[ Under 1 Yr.IIP Under 24 Tire
<br />Ite� Irthda)) I Day 1 Hours I Min.
<br />g �e. n
<br />laa. USUAL OCCUPATION (Give kind of vra k� lob. KIND OF BUSINESS ]I. BIRTH- (City, town o county) (State 12. CITIZEN OF WHAT
<br />done during moat of working Iite,
<br />even tt retired)I� OR INDUSTRY p E r fore "gn ceup try) COUNTRY,
<br />Farmer j o-C A- r_cult_Ira) "%.rren SOUnfvf
<br />lOFla USA
<br />13. FATHER'S NAME lda. MOTHER'S MAIDEN NAME ldb. NAME OF HUSBAND OR WIFE
<br />George 'If. 7,acy Teary TOine Parker Alice Lacy
<br />Io. WAS DECEASED EVER IN U. S. ARMLD UHCES7 16. SOCIAL SECURTTY
<br />(Yae, no, or anknown)I(lf yea, war dates
<br />17. INFORMANT'S NAME or 3igtutura & Addrna
<br />give or of eervice)I NO.I
<br />DIO
<br />�.2C': r'?g Oi♦l tk7E, ?-Ta,�t]'�nj�5 $taiSe HO
<br />S'
<br />nP1P SLOP PhT Si
<br />18. CAUSE o f au DEATH
<br />M
<br />Eneofor n(e), (c)
<br />MEDICAL CERTIFICATION
<br />1. DISEASE
<br />Inte" Between
<br />Ib)� and
<br />OR CONDITION
<br />DIRECTLY LEADING TO DEATH-
<br />Onset and Death
<br />-This den not mesh tha
<br />made of dying, each u
<br />ANTECEDENT CAUSES ,
<br />DUE TO (b).COrOnar4_ art erlO sclerosis
<br />heart idlare, sethenls.
<br />ate. It means the d4-
<br />dL
<br />_
<br />... .. _.... ... .......... .._ ............._.
<br />MerbW eandltyaa, if anr, giving
<br />�.__.__._._.._......:
<br />nee, A.me er rthe
<br />-
<br />lion which <aveed death.
<br />rla- y tka -ben lose (a) .teth"'
<br />eke vnderlring cause Tut. DUE TO fc)
<br />II. OTHER SIGNIFICANT CONDITIONS )1I'f)7 C "Z• "•n._�Ome. - --
<br />Condltlone contributing to the desth but n tC a=g (1C1d yP.
<br />%
<br />-- ._........- ._........._
<br />1
<br />+
<br />related to the dixue or condition causing death CP7 IIr't� q7' �;.SCl C57.S
<br />19a. DATE OF OPERA-
<br />TRA-
<br />196. MAJOR FINDINGS OF OPERATION -
<br />20 AUTOPSY,
<br />Y. ❑ No
<br />23a4 ACCIDENT (Specify)
<br />SUICIDE home,
<br />216. PLACE OF INJURY offir In about ,)
<br />farm, factory, street, ot[lee bldg., ate.)
<br />21e. (FT OR TOWN) (COUNTY) (STATE)
<br />(If rural area, write RURAL)
<br />HOHICIDE
<br />21d. TIME (Month) (Day) (year) (Hu n)
<br />INJURY OCCURQ
<br />211. HOW DID INJURY OCCUR?
<br />OF
<br />121..
<br />While at Work
<br />INJURY m
<br />Not While at Work
<br />22.1 hereby certify that I attended the deceased Jrorz....':?'r? 1,_2., 19......, to.:1111Y... 2C!....., 1911., that 12asL Saw the de-
<br />ceased alive on 111Y..�..Z)-. 19.. CZ., and that death occurred at ?.:�.rl?a.Tn., from the causes and on the date stated above.
<br />Y3a. SIGNATURE `i.4.� �, _- (Degree or tltle) 123b. ADDRE98 I -28c. DATE SIGNED
<br />-.Ian �. �._ Tn-lcsi• Vet,
<br />Car (LOLL-2-1
<br />; -,
<br />_ ?SL1 WU Y ZO l9rj
<br />'b
<br />_
<br />24a. Burial ® : F. TV -.'tii? t, t7F CEME3'ERY OR CREMATORY Std. LOCATION (City, town, or none ty) (Stay)
<br />CREMATION
<br />REMOVAL �ygpe 1LL; 263 ip .�.1iip Cemetery Phillips, 'iebr.
<br />DAT RECD RY LOCAL 1 4'" 9R d 'I('NA Y ,t -' -%` / l 2 U L ECTOH S SIG URE —D BEG A
<br />)e
<br />I
<br />777
<br />
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