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B <br />4 <br />r 7T l_.C11 . <br />Statistics ivislon or YIIai <br />—V ntA m t¢Kt� c <br />4050 <br />CERTIFICATE OF DEATH <br />,.ate! nsttI tioarreve in N E <br />- cead o atree and number. <br />Length If residence in ci or town where death occurre(�,� <br />-.7 =. mo......._...da. How long in U. 5. if of foreign birth— ._7r_mo —da, <br />2. FCLL NAME ..... ......... t - <br />Residence.... _.. ..._ Z <br />VERSOVAL AND STATISTICAL V TICULARS <br />3. SEa 4. COLOR MEDICAL CERTIFICATE OP DEATH <br />ai RACt�I 5. 5 g1e (\\'rite the wor4) <br />211 DATE OF DEATH <br />D _ <br />t orc <br />\\ ca. -red, /F s u. . /`/� 1 / H '._E'._R.E_B._Y _. . CERTIFY. -T.h eased from , <br />I attended d.. <br />eHUSB AND of <br />E of -IF <br />I last saw h-4-* yTive on... ✓�jG -_1. <br />�E.-�- � � 19�'; death is said <br />6. DATE OF BIRTH (mo (d y) (y �^(. to have ­u* <br />ccurred on the d to st Led abov <br />The principal cause of death fat causes of importantt is order <br />7. Age Year I Months I ^Days �If less than 1 aV �i —et were as follows: <br />-G• 7 xrs......... nr Idin..— f„' <br />Data t <br />S. Trade. profession, ➢articular _ <br />1. tnd of work dune, , as spinner, <br />F sawyer, bookkeeper, <br />t 9. Industry or box, - to ril Q `�J�P (re <br />6 work cans done, as ilk ,1 ( "'"f- r{r,`J <br />saw mill. bank, etc. <br />10. Date deceased last worked at 11. Total time (years) ......_.._ __.__.._.- _._.._ <br />this o cupation (month a spent in this <br />c n or causes f tm r .,. <br />ear) cupation "— Contrihrt y portap- not 1 ed to Dfi cipal unses: <br />City or town <br />12. Birthplace and <br />State or conn[ry <br />13. Name If Father / � "Owi i <br />I Name of oP <ratioa...___....�._.�_.�z_.. Data os <br />H. Borthplaee City and own - - " —.. T What test confirmed diagnosis I. -_was there. an autopw -'.(r„ <br />Father State or country - �= <br />u. If death was due to eateroal causes (vbkna) 511 !o also <br />15. Maiden n of Mother //iy following: tEe <br />a Accident, suicide, or homicide?___ Date of i¢Jury_� 19_ <br />3 16. Birthplace City or town .— _....__f Where did injury occur? <br />Mot and ll//((,, (Specify citl Or town, co¢¢t7, a¢d $fife) <br />ther State o cant Specify wbethe, injury occurred in I¢d`uX0" in Oomq or !e p�lla <br />17. INFORMANT ! ple. Y. <br />(Address) <br />Nature of injury _. <br />28. B CREMATI i 01 .RENO "� -'-` - -- <br />eye y4. Was disease ury in any way related to otx¢pa p( <br />kta <br />rI Place._._ U �f _ <br />deceasad?- <br />19. UNDERTAKER <br />(Address f so, specif <br />a33 <br />