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<br /> •t�wrTwrw ,.o. REWSTrtwTION D ��� � � �J G '7 V� s��rnnt � ' � . .
<br /> i oisracr No.
<br /> wTe os ��uHois �u.,.0
<br /> REc�srareco ' MEDICAL CERTIFICATE OF DEATH•
<br /> NUMBER . . . �
<br /> � " � OECEASED—N E /�n• r��ow� �wtr SEX OATE OF OEATH I�wrH. ur. vwel � �
<br /> ,�w�T.�K � John ^Rig" Dshner Z, idale �, October 2� � 1969
<br /> lwr�o/ W�sen� �CEwwir[, at4o, A.yMKwH twaArt AGE—usT • UNDER 1 YEAR • UNDfR 1 DAY OATE OF BIRTM u�ar�•. o.c �w� VLACE OF DEATH CWr�r .
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<br /> � BIRTNPLACE u*wT( Gt ro�uw CITIZEN OF WHAT COUNT0.Y MARRIEO. NpVEB MAqqIED, KAME OF SUAVIVING SPOUSE u�wiit. Gvt rwsLtrr ,uwKl .. �
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<br /> �•�_ � SOC�AI SECVRITY NUMBER USUAL OCCUPATION , KinD w suSwEu on �Nousr0.r . . . � �
<br /> �U.S. wA0. VETERAN . WRR OR DATES OF SEAVIGE
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<br /> RESIOENCE STAT[ ; couwn • urr. �o.n Tr1. M p�p }1f�KT q ' 1�/LMtlry • STI(lT ANO MYY�fR � � �
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<br /> g �NFORMANT' S1 ATl/RE � � REU710NSMW � MAIIING AODRE55 tsitaci �wo rw da �. s. o. c�n at iowr�, frwT4 2�q � . � �
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<br /> iART I. OEATH WAS GUSED BY: (wru wtr ONE <wust sq uw� sw p�, �e�, .wo k�l �(jW(fN*p tfT � 04�M
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<br /> 3'""'"'�"'"""" � 19a/r . . ` . .
<br /> � _-_____ DATE OF OG£RA710N, IF AN �AAAJOR FINOINGS OF OPERATION . • . - � ' �
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<br /> D__�._�."'_ 10a. � � � :ZOb. . _ . . . .
<br /> � GERT/fY TMAT TO THE BEST OF MY KNOWLEOGE THIS DEATH OCCUARfO AT M., NOTE: tF AN INIURY WAS INVOlVEO IH . � . '
<br /> - ---�--" ON THE DATE� AT THE PUCE ANO FROM TME CAVSE{5) STATEO 't � ]� � THIS DEAiIi, TME COAONfN MUST �. � . �
<br /> ��, S BE NOTIFIED_ � .
<br /> • � ; ""��"�"' 1 A ENOED TN �n . Wv ��u�/�� . . wr � rLu � n..o Wr snw wu/ MwrH . uv. . rcue " _ � . . .
<br /> DECFJIIED FROM: /1 ��I � CJ O /O ��� � • cR wv� oH: / �� .
<br /> . 276 •� Zib ' 41a � ,
<br /> SIGNATNRQ � , OATE' SIGNED 1 w. wv, ruq . IWNOiS LICENSE NUMBER . , � �
<br /> � �,.► • �Ls�1�sr�J • .� � n0. �v�^9— � �:� / .S�' ;
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<br /> BURIAI, tltEMATI N, .CEME7ERY OR CREMATOqY—NwME . LOCATION cm oR 1w.w sTwar , DA wa,M wv, vwy '
<br /> REMOVAI 1��w/ � . . . �
<br /> �.a. Burial �a�e. St N' • s � z.�. ' �ncoln I1linois : z�e. Oct 0 1 g '
<br /> fUNEM4 HOME NAM sn �rio wuwu ae w. r. o. un oR iown srwtt 2N , � � �
<br /> ssa, ke hiemox3.a1 me 29 S. Zo an St Lincoln Illinois 626
<br /> � � FUIVERA� � S�GNwiu � , � . rw.nw� a�.p.eta'a nu.a� a.eu.x e�w.ae _ . .
<br /> . D � ' �Se. �'Jc+6 "- • .
<br /> • LOUI 'S GNATURE r � OATE � ' BY IOCAI REGIS RAR��-. �•. ++ . � .
<br /> 1 � ca�rnn_ � � • z�. ��'
<br /> �^t� . VS 20�(t968) uutiqs o[rnwtu[r+t os weue wuir.� — evec. r srwnsnc cWto o.. ��s� u. s. srwwwei eeRnrKwrcr � � . . . � .
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<br /> STATE �F NOIS '•
<br /> COLJii'fYr��+.01r I:dC�1N � ''� YS��� . �
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<br /> r,`i* �•�"�i,�'�j} don B 7'rrantz , County Clerlc , withtn and for said County
<br /> and Sta�g aforesaid , c� 'h6rg " certify that this is a TF,Ur PHOTO COPY af the record .
<br /> E on fil�. }se' �s_ �4 �,fi� ay ��7'E; T�ST2:�10 ^7Y �'HLRrOF , I have hereunto subsc �ibed by hand ,
<br /> � affixed �'� flPF�E:Ij�I. ,�AL ';of said . at my ofEice in LIIiCOLN , ILLiNOIS
<br /> this �'='�F 'T+��� *�f - - -���y�— ---- - - -- A . D . , 1978 .
<br /> ,� .
<br /> . .. , + r 'l_,, t•,, . .. � '/� . . .
<br /> Weldon �. Frantz , County Clerk / �� �'
<br /> Logan County , Illinois �� '7 �S� f 1
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