Ms. 300 10.40 THE DIVISION OF HEALTH OF MISSOURI 2624 « FILED'SEP 7 4958 STANDARD CERTIFICATE OF DEATH sia eta LG 7m. nis rer 0: _2EP onan mest. ne _L0Oe- inate OOCO Ponce OF BERET USUAL RESIOENGE (ibe ibm holmes ma CUNY son “SATE Wi geourt eatin Pages a a a ee [> Pree nesses oh oa “STmain| SraV cage soe foars| TOW" Kansas City a ica 6 FULL, AME OF (twos howto tate, rok drome or leat SRE ‘GE eral, hve loestond BLT % WenrchoN BtecJosephiHoopital,, hs *°RES 1550 Wiohole Parkway o TEESE tno sm a Tige oar Ga) eo (Type or Print) Samuel Higginbetheam okra Ange 19 1955 BSG op [OCOD OF ET FARRER SST | ONE OF HT TAGE epee eet a [A Sea | a aa" ses ot |_Mare__| Waite ral 1875 _| ! TUS RTP een | ev or EME GEA | WOMBAT ‘etirod beck Sargemt Kan City Police Dep. Saline Co Se. raTHER’s MAME 3. MOTHER” s WALDEN NAME 1d, Wane OF HUSOAND OR WIFE William Higginbotham Johama Davis Blanche ab L Higgingbothan Torsige Gue ) WSITIBENOF WHAT county AT if AS DECEASED EVER IN US ARMED FORGES | 16 SOCIAL SECURITY |. INFORMANTS SIGNATURE OF NAME ‘ADDRESS ajaneraninns) [inate weer an eri) Blanche L inbothan 1650 Nichole MEDICAL CERTIFICATION ERAT tgplsease op coxomon, sa REEL EERE Bani “Fao er nen MeréeDanr cases Da Lisraclers ; ‘the mode of dying, such | forbid conditions, fens. -fiing DUE TO (b). ‘rheutflareetenie, | feo sce et (a te tt means the dy | Re undeining cou fa ane npr romp. @ 2b 2. gad Sera |Toma senmcar conan Corasimmatn . SEPTATE, Cancoma f Hclny Segall raed 331} "So, MAJOR FINDINGS OF OPERATION a AUTOR Ta BPAT Seay] Be AAGEOF UAT agin | ie TIT. Ta OF Tom SOON) AT sane ERR Son ae sects Bebe Tac TMeaeay wan Wan Gow | Ho, ORY BSSIRRED” | Wow BO UR OAT weiter = SEE Sear 2.1 hereby certify that 1 attended the deceased from Thane ~ 19,52" to » 19:95 that T last caw the deceased alive on 19.5°5-, and that death occurred at L211 °C m., from the cauffa and on the date slated above. TURE eee Ey sears ‘Be. DATE SIGNED, 5 | 4 5 § a 4 E 5 FURTAL CREWA] 2G _ Bene Wel Zee, NAME OF CONETERY OF side a. sgourd, DATE RECO BY LOCAL | REGISTRARS SIGNATURE, B FUNERAL SinecYon's s\cuatuRE Toone 20 rales | Mellody MoGilley Bylar Kansas City Moe ‘Ciccone Emaloe's Seatenest 09 Reverse Side)STATEMENT BY LICENSED EMBALMER I hereby certify that the body whose name is recorded on the reverse side of this certificate was emt by me, or by .. Student Embalmer No.. ZPD working under my personal supervision... Student... iegatace’ of Siadeat Babak P, O. Address Note: The above MUST BE SIGNED BY THE LICENSED EMBALMER in his OWN HANDWRITING. (1 to comply with the above constitutes grounds for revocation of license). If embalmed by a STUDENT, he also shall sign in his OWN handwriting. If this body is not embalmed, fact should be so stated above.