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<br />- COCAt F1~ M9ER STATE FILE NUM9ER
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<br /> ,. Clarence { ~ WALTER 2-`,4aie s v ~,. 19.x?
<br />' RACE-Wnse; 8iect, Amancen InOian: AGE - lAai UNDER t YEAR UNDER (DAY DATE OF 81RTH I MO.. Dap, Yr 1 COUNTY QEDEATH
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<br /> . White s.. 89 en sp le Fehrvar ~2O 18431>a ~ellowstcsne
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<br />i' OSPITAC OA OTHCA NSTITUTION Name . :not m ntl»r : y+.e ae.«I arm rumoatllF HOSA OR INS ~ a care DOA,
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<br /> RESIDENCE - 3T1TE COUNTY CITY, TOWN, OR CQCATION INSIDEC TY LtM S STrc`ET AND nUAtec=•
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<br />.INFORMANT-14Y!(Type or >rtnl) MAILING ADDRESS..'STR'cET OR R.FD NQ' CITY OF TOWN STATE' =~`
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<br />CEMETERY OR CREMATORY-NAPE LOCATION CITY OP TOWN:.. STATE
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<br />BURIAL CREMATION. REMOVAL. OTHER (Specityf MCRTVAAY OR OTHER ~ NAME ANC ADDRESS ,
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<br />ACCrDENi.-SUICIOE nOMKWE UNOET. DATE OF INJURY IMO.: Day, Yr I n0uR Of InJ:1Ry DESCRIBE HOYI INJURY OGCURRF.D
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