HomeMy WebLinkAbout0604 ~ . 2~338~ ~
KOSCIUSKO COUNTY DEPARTMENT OF HEALTH
fILEO AyC ~'ECORQE~
ST.1.UCtE CaUNTY FlA• ~
Record aocEr. =o,Ya~?s
Of Death CLERK G:' :J~T COURT ~
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TIiIS IS TO CERTIF'Y Hiram Hunter Van Cleve ~~8 ~ 151 H~~~
That our records show - ;
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January 6~ 1973 Kosciusko C.,unty ~
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lionth Day Year Hour of Death County j
Age at death ?2 Sex ~le Color ~hite Sc~cial ~ecurity No. ~1~-~-?355 ~
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Primary cause of death given was ~espiratory Arrest #
Signed by uarold A. Mason~ M. D. Warsa~~ Indiana
Physician or Comner Address
Place of burial or removal ~akxood Ce~etery '~larsaw, Zndiana
Date of burial ,Jan. 8, 2973 Titus ~`tinera~~~ome Warsaw, Indian3
't Funera! Director / ddress
(3EAI,). , • ? : ~ . ~j(/~ ! ~ ~
_ . - , Signed ~ Y
. , . - • ' January 1lt, 1971? "
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• ~ 1 ~ ~ CH-1!t 6~
: . $~~:1~ ?~c~ ~Q4 ~tec.~otded locally in Book No . Page _