‘MAR 24 1934 MISSOURI STATE BOARD OF HEALTH| tenctueatsmce BUREAU OF VITAL STATISTICS |, ‘CERTIFICATE OF DEATH | 1. piace oF oeghu County ose Rehr Distt NO. om SOE. Townships. seovonue Polnary Registration Disrtet Ne. S.0.7.9.. (i aly ive iy i toma iat de_Morlogin U.S, etlotgn eh yee men de i PERSONAL AND STATISTIGAL PARTICULARS ‘A. MEDICAL CERTIFICATE OF DEATH t INC (ARRIED, WIDOWED, OF 5 y | “{COLOWOR RACE | 5 Sncie Mannie WioomED.. 21 OATE OF DEATH Quoi DAY, AND YEAR) ST A > | HEREBY CERTIFY, That 1 atyended deceased from Tete oll EAA LE Be PERLE. Gi, Tmt aieen PELE 2S 9 WBS) ba nce to here cecre onthe dat said above, 2 P22 ME, Toapuacal case of eet and red aw of pence wee foes se Dig eg sp Ragen ste et sian ge ES sous BIRTHPLACE (crTy on Tow Pi geate On Coun 14, BIRTHPLACE (erry on ron. Mt PUETAIEONOUNTNS £29, Jf death was doe to external eau (valence), il a le th fllowiag: Accident led, oF hom? onnnrem Deve far 33, Co rr ‘Specify whether injary occured ta tndustry, ta home, arin pablle are. ESTok Re IN is very important. S IL THEY ARE COMPLETED AS PRESCRIBED BY LAW. statement of OCCUPATIOI eminog Sue MISSOURI STATE BOARD OF HEALTH ALL INFORDATION CALLED BUREAU OF VITAL STATISTICS FOR UST Bg LAITTGH OF) ‘CERTIFICATE OF DEATH ‘THIS SUPPLECIENTARY, Redes Dia Ne Primary Begletraton Disset No..52-2.A..L) LOK. i tv Ry i towa a” Tre__mut__ des _Howlensla.8,ifatforrgntt oe nag, PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH 21, DATE OF DEATH (MONTH, OAY. AND YEAR) Lb 72 034 ao mene ‘That T mttended deceased from Theat Bo A 7 i to have occared on TH > | canon of CE | 5 gee em owes oa LE Sree omens a or onTE oF oT wo on aa ria a TAGE YEARS “me DAs 875 wooo SIRTHRLACE (ry 98 TOM. 1. BIRTHPLACE (e198 TOW orn {STATE ON COON 15. MAIDEN NAME 2, 1 a ce te) i ‘Accideat, uid, oF hemlet Dato Where di fury occu