Laserfiche WebLink
U <br />r, <br />j. <br />yy' <br />I! <br />4 <br />- DEPARTMENT OF GOhf]fERCE <br />B., o. rm. c .ace STANDARD CERTIFICATE OF DEATH m Nor wwzs <br />STATE BOARD OF HEALTH <br />/ a a O <br />206 6520 <br />IN TATS 6PACP. <br />Dirision of Vital Statistics, State of Kansas <br />Registrar'. No__._..._1��........ <br />1. PI.AC.L OF DEATH <br />2. USUAL RESIDENCE OF DECEASED. <br />(a) County 5.QUTbpII .. <br />(b) City or t wuship_.. Fort-Scott JSe. (City <br />'t �l111, 0 <br />(a) state _..._Kansas...... -. <br />(If d orro W 's <br />Nam of hospital o institution: <br />.. -Burke St. -. dieicy ifoa�Lta1 ._ <br />(c) City or town ort -Scott � - <br />F u BS <br />i of eeo,c no» ro� or etm< mr n renore ) <br />(d) Length of stay: In hospital or institution.- _1 1k <br />(d) Street No.... .706 �GUoh - - -- <br /><u o.r i «m'oN <br />(sc «dr hotn.r._ <br />In this commonitY-... 1.._ yr......_.._. ....__...._ .................... ..._..... <br />rear <, inner., or a.r.) .... <br />......._.... years <br />(e) If foreign bom, bow long in U. S. A.7._- _..._... _ yen <br />i <br />3 (n) FULL NAME. ichard 0 Ames <br />MP;nrcAr, csazrrrcezron <br />_. . _ . _ <br />3 (6) If veteran, 3 (c) Social Security.•. <br />20. Date of death: Month_....!.'. .. _.....da y.......2+........_.._._... <br />rear__. _1943..._..hr..........8....PYI minute....._........_......_. <br />.mine wnr ... <br />..................._........... <br />5. Color or <br />No.. ......_..........._.._. <br />6 (a) Single, widowed, <br />er by ce�rtify tout I attended t e deceased (rom__ <br />2l. I / w .43 <br />4. Sex_ma1e.._ <br />r @t? .t.� <br />roamed, divyr d <br />......maST.F..e.A <br />..._.... ..._. <br />toot I 1st saw him...1we on....._ . u ...5 ....................... 19....¢.3 <br />6 (6) Name of husband o w fc .. 6 (c) Age of husband or <br />wife if shoe <br />and that death n d the date f d on stated <br />above. <br />f •, <br />^" <br />Marget...Amea .. No re _..yeare <br />7. Birth date deceased. 8 ent (. lyl{V <br />Imm,dipteey use �ra yn ..... <br />RFFr.rf �. ^ <br />of <br />of •/_ , .. <br />(Mnvth•._ <br />SC.Pf/!M 1. QM�P141 <br />/:.•J1 <br />B. AGE: Vcars <br />Day <br />I <br />If less than one day <br />- -" <br />D to .. _... .. { ) _. <br />... . 1 <br />IMonths <br />62 <br />/ ? <br />? <br />h .min <br />i <br />B. Birthplace. ..IIO.. SEGOTd.._.. IZZH._. ! 2 <br />(sraeor for <,� <br />ty �).. <br />or to .... <br />..... . ... .. /) `� / <br />l fr 'YC(0�l41P INI <br />......... <br />... <br />10. Usual occupation RetlTed $BFmeT ........ `` <br />11. Industry or busine®........_.__ ...... .................................. .___..._..l.... <br />Other, conditions YOHfL <br />(n,,I dsproac+crr d —sahs fdmm) <br />ymr.rar.rr •. <br />.. 0 ( 12. Name ..............7d0.._I.�.QL) SCE,.............. ............._................_ <br />.... -a.or findings :............._ _....._.........._......._..... <br />M <br />uostc, o <br />JJ� <br />(S 13. Birthplace ....................... IlO.. .YBCATd........................ <br />(Qty, tins. <br />Of oPerations......._._._......_...........__ .............................._ <br />the ay. a 1 <br />which death <br />BrthpleceQ <br />. o ,;oTtlro.._rP,..eObio..rw.wtry <br />22O Ifd ethwnsduetoexternnlaausce ,..511iatoefo11ow1ngtlYG <br />16 (a) Informmot'e own eilm.ture� . .. ... <br />(a) Accident, suicide, or homicide ( epecdy)... ._....._............_._....._._ <br />1 <br />(b) Addre ss.......... B.tor- t....BCOt- ............................ <br />(6) (6) Date of occurrence_....._.._._ ................_............ .._..............._........._.. ' <br />a ......... ._. <br />17 () >5yrlal..._.... (b) Date thereof........_._.._.. <br />....... __. <br />(EVriJ, erem�Boo or romowl) (MOVth) (Day1 Vsr7 <br />c Where injury occur ....... ............................... .. .. .... _....... <br />() Wh did 7 ... .... 1 <br />(City � <br />(orate) <br />(c) Place: burial or cremation....QY _..fit 'OVE,, libIIE <br />aCII) l;H injury occur in or about home, on farm, in industrial { <br />`. <br />1a m) aig�eure of funeral a; rertar ._._Konant.�,_,_,1!.}�per. <br />e• in public pl ace7. ...... _ .... _ .................... _._.................__......... t <br />Hd'�& '), ry tywo P�eoe> � <br />(b)Add(?sa �._ _.....For.t...S(�jiQ�t ..........�. %.. '...yyf..�. '..ffY� <br />.; lB (a)._._.ILh..3__19d'i (b)fliJ4_d.��.n>.,/FKe.I <br />While at 1�o//ryy)��.............. ... M.— of injury..__.............. <br />�. 8i�attq{',�.¢.4.1116L,L; QfC?1C... (M. D. or other),...., i <br />�3� r <br />