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1, Harle' A. Wolfe. Quk of 'I~e County Cou:t of Herrison County. Wat V'u~iai~. and as .ueb
C1erk having the care aad custody of the Record~ of Deaths of asid Counqr, do certifj? tLat d~e a~id
Records show tLat ----------------~~tt~~a_~1iOL----------------~_~--------
died on the day of -1~L•11---------------~ aad d?at tbe Records eonhi,~
the following additional information concarnin~ t6e said desth. viz:
Place of death: 1. Harritoa Couaty
2. District~ town or dty ----~~"I[!~~(~-~~_p.a.t T~..A._.~.__~
Sez: ---~a----------------------------
Color or race: --~i~
NLrried, aiagl~ widowed, or divorced:
Date of birth: ---QttOtti~tL.21.~-1•~-----------------------------------------------
p?S'~~ Y~ mont6a ~ri
rILEO A~to ~ECOROED
i Oocupation: __..~i:'i~l-----------------------------------------g~.-t-t+~l+?'~•.:'i~''t"}~L~.
k B~~: w!~~ ~~.s~~_ , . . - . .
E Name of fatber: ---~Q4Z'jt ~~~1----------------- j6~~i3~
~ B~p~: -----------------------------------'6~ M~t~^--~ 3--~ -9 = 34
~ Maiden name of mothu: ---~i~'~i_~-YOliti~f~-------------------------
~ Birthplace: N----•--- --------~~}iE-etf~Etft~E$ttRT
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~ Date of desth: ----~~„]r~~~-~,~.'f_------
~ Date of burisl: ----~~-~s-~~~
~ Cauae of death: ~1~--#.~~9itiAi~l+r--------------------------------------- ~
~ Contributory cswe: ------~r~l-i~l~~flS~l1'r~i~-------------------------- ~
; P1sce of burial os seanoval: P.i~i~.- ~'}1~-~1~~r
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~ Uadertaker: ------St..-T~.~`~t~ -
j Phyacian signing c«tifieate of deatb: ----.~t~i~d~.._ ~~1++~•~~~.-~.~-1.1•~ -C1a1'~~ti~I'~ ;
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3 Nasae of infqrmaa~:- -Y-~j~.~..-~~s-~SL~~s-~a~'~Oif.-------------------
~ n.te urtibc.te fil«i: ----~---jlZ'-~-2~--1~--------------------------------------
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N~sie of regiatrs:: ---~d-~II1[------------------------------------------------ ;
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~ In Testimoay W6veof. ! have 6erwnto aet my lund and affized
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~ tbe aeal of tbe said Court, at the Gty of Clulcsbur~, this
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~Y of 19~---•
_-~~Gd.Cl Gerk i
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