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<br />county Record
<br />STATE OF IOWA
<br />IOWA DEPARTMENT OF PUBLIC HEALTH
<br />4UMSER CERTIFICATE OF DEATH 114-
<br />DENT S FIRST MIDDLE LAST
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<br />BLACK INK
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<br />RUCTIONS. SA
<br />SEE
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<br />STATE OFIO A
<br />200010162
<br />rf OF DEATH. MV J)., 1,
<br />ktobar 1S- 2Mn
<br />OF DEATH
<br />county Record
<br />STATE OF IOWA
<br />IOWA DEPARTMENT OF PUBLIC HEALTH
<br />4UMSER CERTIFICATE OF DEATH 114-
<br />DENT S FIRST MIDDLE LAST
<br />lob. H414-1141- L=,
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<br />.DATE OF BIRTH 11111, Day. V,o
<br />*-June 10. 1945
<br />I CITY TOWN. OR L
<br />PACE • 001,44, S14Ck
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<br />SOCIAL SECURITY NUMBER
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<br />T. V. beat PWI r,,y 4 4-9" 0
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<br />.DATE OF BIRTH 11111, Day. V,o
<br />*-June 10. 1945
<br />I CITY TOWN. OR L
<br />PACE • 001,44, S14Ck
<br />A -c.. II'd— As. ISO.,
<br />WIDOWED
<br />12. Marx."j
<br />0 wdAk 69M. sf w—q most KIPM -m
<br />l-Coutv
<br />I OCAT'ON
<br />L -------
<br />!-4SIDE CITY 0MIC
<br />, Sp Cdp yes O+—
<br />)N 'Sor dv only G,o,d.
<br />4a,2i C-111 1" 0,
<br />WAS DECEDENT EVER IN U 5 APWED
<br />SERVICES' 'Sjljcdy y.s .1 n0,
<br />0
<br />INSIDE CI'Y IMITS
<br />Sptol ( ta—,
<br />.801
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<br />M
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<br />NA ANOTITI,EOF ATTENDING j{ IAN
<br />s. 0,
<br />NAME AND AD SS OF CEAT IF IER 1 %AAW o,, Ma,ftel 9.4z- fll,'N'"
<br />,!r. Scott Blair, ME, 3434"'vest way. Bluffs#' I owa 51�5�i
<br />N. PART I Ewa, the a,"Asti. Iw4s, W 'hat caYM01P.t "at, 00 not Am. 1'. 'com OI ayl-q� t"ov, ii CNA sc W 1.0116twy .—I.
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<br />4.1h) LAST ONE TO (OR AS A CONSEOUENCE OF)
<br />PART it 6, If A, IF FEMALE WAS THERE A
<br />THE PAST
<br />AUTO PS,
<br />WEP.EAUTOPS"IN
<br />AVAILABLE PRIOR
<br />PM I.. I PREGNANCY IN 12
<br />MONTHS,
<br />INGS
<br />70 COMPLETION OF
<br />(Spoady .a o,
<br />No
<br />CAUSE OF COATHI I
<br />CFN-58&=21 1
<br />os,*clfy yea 01 -.0
<br />I i
<br />29.
<br />2ft
<br />t1sw
<br />This is to certify that this is a true and correct reproduction of the original record as recorded
<br />in this office, issued under authority of Chapter 144, Code of Iowa.
<br />R
<br />NOV 0 1 2000 BY OF POTrAWATTAMIE 7.
<br />DATE ISSUED COUWY REGISTRAR OF VITAL RECORDS COUNTY
<br />IOWA
<br />C0924898
<br />FORM #686-028C (I M) WARNING:, IT IS ILLEGAL TO DUPLICATE THIS COPY
<br />
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