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LOCAL REGISTRAR'S STANDARD CERTIFICATE OF DEATH 1i6�L <br />STATE FILE NO. <br />NUMBER [ o <br />-�� DATERECEIVED yi 1957 <br />1. NA ME OF DECEASED +•-. aa4 L.t <br />I N <br />^� yi ED:;A ALICE MAIF41N <br />2. PLACE OF DEATH ' 3. USUAL RESIDENCE ,Ir In.r,rur:m. [I.• rv.aer.a unore .niml..Inn: <br />A. COUNTY A. I STATE B. COUNTY <br />Josephine ______ i - Oregon Josephine <br />C LEN <br />B. CITY, TOWN. 'It cuuae ,vrl.o. ale GTHOF— C CITY.TOWN ,cr our. a .ra ltmrr. ...oaurl <br />ORo.,u.. .n. STAY IN 2B ORwp <br />LOCATION Grants PA.S`C I.7 ar LOCATION Grants r - <br />a �$ <br />D. NAME OF HOSPITAL rir -I +n —l"I. [,vv -11— aw.vul Q STREET ADDRESS. RURAL RQUV. ETy. <br />OR - • <br />INSTITUT IONPa rkyiew llursin Home - -'- 108`S= E. -B . ea re Drive' <br />4. DATE OF a�oa. a•a' Y•a. B. 8EX S. COLOR OR RACE 7. MARITAL B ATU! <br />DEAT "October 18, 1 White ° Nara 0 =—m ' <br />❑ nl.aw p sr.ar r..lw <br />_ <br />S. SOCIAL SECURITY NO. I S. USUAL OCCUPATION 10. NRIND OF BUSINESS I -1. NAM[ OF S-UiE <br />tlu ,...ne w Iu.I I Y7 epiUBTRY <br />i06 -28 -8820 Housewife <br />72. DATE OF 113. AGE LAST BIRTHDAY I IE Uwn.[�.I_v[�R__.. �oUM <br />BIRTH <br />October 6, 1F84 4 73 Y <br />14. BIRTHPLACE (441. w va.l towln -1 1lb WAS DECEASED A CITIZEN OF I IB. IF DECEASED WAS A VaJERAN. <br />Fairbur Illinois ° "'" _A:: <br />I7. NAME OF FATHER �. 18. MAIDEN NAME OF MOTHER 19, IRIORYARf'[ RANI AAO <br />Unknown Unknown titer <br />20. CAUSE OF DEATH —r,•.... ow[ o"[ <br />I rAt. Ia I. ANOI 1. I•YV••1 [a•e -vpmmt r[yy <br />PART I: DEATH WAS CAUSED BY; c <br />INN EDIATP.)CAUB¢(A): .�+I�i( ..//�� ♦ —����/ <br />I DUE TO (8): //� • _ _ (/ (1.�_ %� }�, • (. . <br />( Iylnr awe wt r 1 DUE TO (C) <br />1 <br />T lI: e.nt CoMIUo ( 21. ]r •a.a.a au l•wr. aru tbn •I sa.tAV1vM' <br />no< aora w •[.mm7 In N• aW Ia m"MS.r <br />I.v o.0 eonGitlon [I.•n Q Y ❑ No UpYrgwq �Tw �No <br />23.1ov o[ al 0 24, Ir I Nr, oIO .N.cR 2D x.� Ac .... •28[. Clb Carob <br />T I D w i•rm.IHane. 1 <br />" O "• .T�[s Al. —M. O A[WmY [ `t Work I ' <br />j 28. TIME OF r xow Ro�u. Aar —.. 27. DESCRIBE HOW INJURY OCCURRPD., <br />iINJURY ............ •. m. '.. <br />28. CERTIFICATE: •.... ....._y.._.. I..... <br />I C•.xly My 1 atrnCw),Lr!R[,�II�I�•rl u• C••w3A 1 a I <br />2b. RESERVED FOR REGISTRAR'S USE <br />.o...... A.I. A. Ya[. D <br />j, <br />l <br />�J <br />tM <br />m. Fe NIIF4lII.» ".M en <br />• �r.�t tp• ".•r .rw •t ..._! a <br />.D. Grants` Pas.- SAMon- l0 -19:57 <br />ITIU•) IAw.ag car [yaw <br />Grand •Island•Nebrasl <br />R[CT '[ t10NATURi AND "O"N' Pass,Ore <br />.5-117 <br />JAN 6 1960 <br />I <br />i <br />l <br />