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94s5 UNITED STATFS OF AMERICA. aECOpo vfa~f~0
COPY OF REGORD OF DEATH 9~~~~ ~ ~
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I, the undersigned. hereby certify that I am clerk of the ~.......oi........ ~l
that ~a suc~ I hsve cuetiociy of tite records ~?f ~i~~t~is F~~ui~cu hy ~a,: ~ u~ k~,~t fa ~ a~re;
that among euch records ia one relating to the death of
RAATR I~S., rt...
~...ARI!C. VBItI~Y
and thst the lollowing is A true copy oi so much of aaid record as relstee to eaid desth, namely ;
Dste of death......... ~ARCR. . . .
~~R. 1~
AULL, lUl3SAQi~9aT?8
' Place of death
N~?me Beatrio~.l[. Cla~k. Yir'r'~!+. wit~ o!. N~~!~r, w. Yirs~r
s` If MowMd i~ ~~c*iei. ~ide~w~ ~ ~ihro~ ~w~~. ~i~e Nr a~iis r~e W~~~of ?rM~i
` .....g~1e1~....... Color ~t~
; Sez
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! Sin~le~ Married. Widowed or Divorced ...................~ild.................. '
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Age Yeare .............j........ Months .........18.......... Dsy~
Reaidence ..................i5 . ~et~a!!!i. A!~• a...~i....................
Occupation Hou~ewil~.............................................................
U. S. War Vetersn ~
Quie~O~?~ l~ai a~i
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Place o! Biith ri~~tt• _ .
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FATHEB ~ MpTgEg ;
' Name a• Q ~ Maiden Nsme ~t~da Duti~tati
------------------.lask------_____~_.. ......._._...__.___--__.~....._---..w._....
Olouosater, 1[~~r. ~ Qu~pp `
Place of Birth ~ Place of Birth._._..._..___... r~ ~
Cauee of Death ..A~.°..rio~°le~oEio he+~rt di ~ss~• •~a~~ial 2f~p~rta~l~ioD
Place_c~i Buttlsl .........................~1.............Name of Cemetery
D-,"s~~,o['.,~edrtk
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. ...__._....__..._..~roh 23~.__1~........------------.._..._._.._..____....-------.._._._._...___._.....__---
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Li ~ And I do hereb certif
'+T~' ` y y that the toregoing ia a true copy irom said reoords.
.i~:`''~~~'~ j Ft: ~ -
.~.,~~4~ ~ t ~itntBS m,y hand snd ses! of said ..~--ot_..~. i
~ Tenth ~ov~nbs!
~ `;~i ~ on thi~._._.---_-.__.-------------._.~...daq oi.__~._..__._.__._.._.._~.___.18n
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- Cl~rk
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IOpM 4$1 MOB~~ 6 WARREN. INC. NU~LIfM[R~ b~OK~v • PACi~~~~