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HomeMy WebLinkAbout0736 ~ , i ~ i-.:, ,t . ~ ~ ` ' . . . , . • • - o ~ ~ ~ ~ ~.~JI~„`,~. 1:~:~~ I 11=1r:.11 : U1~ ~~~:,'ll~H . i a CcGEA~W T;r1b~E ~ "u:u_.. ..`'rT . SEx.._ _ "DAiEUF~DtASN 'i•~wt~.ti~i,iN~l • , ~ . . i, ~Ic~rq Ireue De11'ee~ ~'criole Apri.l 30~ 1974 c) . o~ R~ICE [y M{•Np 1MNIC11 V 4M >GE ~,u ,,.Ur ~ER 1+E 1k 4`+J~ER..L.D_~Y OAIE OF 6{RiA ~~owr~,o~~,~u~l PUCE Of OEATH wv~n " • ~ liC «1tLlrq MI ~~l ~+la~ MO/ G~1{ OYM{ MIN~ ' . y ~ ttiI~ito 6~3 ~ ~w~Juno 14,-~t-9~11Q ~o. r'ulton R y~? ~ ?M1 '`j~ CI~M,~10~M~ iwl~ OR kO~P D~II+~ii M~MIQ i(MIMMO~rr i' MON/T~L W OINM IM?11fY11OM•N~ 1N MOP IM ~WMi1~ 4N'{ ~14« AMO MY ~ I r II R F~ ~ y Cantoo~ , r~ Yea ~~a Graham ~ospite 1 : 8!RT'HP CE (tt~ft o~ ~c?ua. C1111fN Of WF1At COUNTRY MIARRIE NEv R MARRI NAM URV~YIN U l~uow wK, v.NO A' ~ cowu~ W100w~D, OIY A D~ ~ , r ^ y ~ Tonnessee ~Ll.~USA ~a blarr~e~ N~illard De1~eese : ~ SOCIAt SECURifY NUM9Et USUAI QCCUPATION ~~+NO Oi WS~Ntss Ot u~DUStrr ~u,W~ VET R/W ,WAI OR DA1ES SfRVIC . ~ ~ ; ~~:~!9.-.~~~Z_ Teachor si~, Pnblio Scbool t~~, No ~ -;~~e. r°~ 0.ESIDENCE wu"n ' air, ioM'w n+r. o~ ~o~e o~v~Kr M-a ~~uot e~n ~ I1R[U ANO MYM~{~ t:• t 0~ i i ~ftWMO) ~ ; ~b Illinois :~~b, ~tasoq IIavaoa ~~bYee ~~,i., 227 5. Me Kiotey ; ' ? .....~.,....~...~.....w.......,.....~.....~r..i> ~ iz~ n a F A T H E R-- N A M E n„~ riDD~l wr p ~ p M E!- M A I D E N N A M E ~ ~ . p 4 ~ M ~ p s. R. Gi1lilaad i Lela llont omery , a. ^ u~~an +w xo, a~ r, e., ~m o~ row~, a.rt ~ INfORMANT'S SIGNATUiE ~Rf~AT10NSH11 ~MAIItNG ADORESS . ~ c"' ~Q ,,,.p', r~,~,,~'/(~ ~'usband 227 S. ~fcRfoleg St., t&+vaaa, Ill. 62844 ~ : 0 ~ unouwniwrt~+K ~ y tb~ OEA(k WRS CAUSfD 115 (c.tt~ ax~r oaf e.ua ra u~e ro~ fd, AI~ ~o W) ~ttwta o.ur uu ou+r J~N , ~ ' ~ + ` . " o MRi l i ~ ~M¦ioi~'tt C~wt " F ' g ~ ~a~ ~r'd~~o^~,.~. ~toc . 6 hf. M ; w OY{ 10 01 ~4 A COMIfCU C{ GI . . . n G ~ p ' CO»GiTiDN1, I/ ~11M. ~ • ~ M ~ %FIEM a~~~ ue~ ro ~ ~"GM~ ntl. y~ Ote.r e~.~ W ~A>s"'''~~. ~ ~ i „ aMwun ew~~ W pVI 10 0~ ~I ~ CONIIQYlN01 011 ~-(J ~ ° , ~ : a , ,~,,,~a ~~o~~. ~ , ; F ~ ~ A s". ~riMa u~it u~~ . 'r ~ ; A M~1 , ' ` { a ~ ~ ~ + u : A~ ~ ~ a° MRT II, OTHER SIGNIFlGNi CONDIiIONS~ ~~atww coaniwn~c +o ouni xR wr ~w+u ro tiw avcM a rMt ~ W ~,~iA/SY Yii. •w ~~.+N w ~ ~ ~ ~ ~ ~~p~o ~ ~ ~ _ ~ ~~M T i N ~iui~r Kn~wM wnt ~ , ~ ~ ~ L~ ~ . ~ M IL '~y ` x.o .~il~ 6 p='~'"_ ~$t~ .y ~ DATE Of OPEBATiON,if ANr MNOt flNDtNGS OF OPEtAi10N s w~i~ +eAi1~ ~'~y,~ ,y i ~ ~ ~ , ~nGO~ ~y ~ „ ~ ~~y~~~ ~ ~ ~ V~~ ~ t ~Oa ~ ~Oy, ~ ~ ~1 ~ef ~ 'h1 GA ~ I A T~~E pE0 iME~~ ~'~",ar,ru4 • MoMt~,o~r,ru ~wp~o~Nw Mowrwa~.r ;MOUt Oi DEAiH' ~ i ~jM~~ Y~, ~ ~ ~ ~j';~ , ~M OECEASED fROAM f0 i ~ ~ j?$1 zie, Q o 4C ,~G ~3o1)~C z~a, .~t O ~ ;,y~' ~`d~'~' 7ta ....___..__4 4 ~ 6s20 P ~ . ~ to , ~r t , ~ V ' CEkPIF'Y TXAT ?19 1'H6 Bf.51' OP 1fY tiNOWLEDG6 TX/S D~AlIIOCCUBRdD NQT6 IF AN 1NJUt1' WAS lNYOlVED IN THIS CEA1N, , y1 ' R K'• p~~;Fj~ ~i~ Ol~ 1'21r: LAT6, A7' TIrE TIVS AND PLAC6, AND fR0d1 TJId CAU36(S) STAl6D iNE CORONER MUST 16 NOTIHEp, W~ )5 ' • ' SIGNATURE ^ ~ ' ~ ,OATE SIGN D 1¦o~twar,w.M ,IIUN I NS NUM ~ ~ ~r~ ~~~~~W 2?o,~J _ 1i°~~ ~12e, Pi$y 2~ 197b ~~36•45611 ?'t ' M,AI,ING ADOAESS--C:~f~i;Et ~r~ce ~ro N~ ~ iR o~ r, a emo~ rowr n~a ` ; ~ CALF'~L4,1 CLINIC LTD.~ 1, South Matn Street~ Canton, Illinoie~ 61520 .r..,..,..,.~.,,...._.~ , ~ ~ ~ 6uPial, C~Ev.AiiON, ~CEMETERY Oa C~EMATpRV-NAME ,l0UT10N ~~n~~~~~ennesse'~'~ ;DATE fMoMr~,o~r.wN1 P:MQ4Al ~t~ttv~ ' ' ; ; ' ~ a~a, Bu:rial ~2~y, Fort Hill ~s~_Clevelaad _ i~c~o-i~_. ~,~~e.!l(ey_~,__1~.~4__ , . , ~ _ . _ . F~NERAI hQME ~AME nR~n ~yo NuM~u o.., r. e. ar. o~ ro.r n~n j~ ' ~ ` Il,~r1:~~~111~7,~~n1 llun~e 217 Y. Almu_.St.,, lf,~ti~ana Illinots C2894 . / ~ ~ i~,! '+l ~i~if fC7R5 : ~ ~i,~E ~ . . _ .-~;U~.teA~ o~Kr~, z~S~~,~~vO~S ~+r~lN6l N~ubt1~~ ~ ~f1 ~ ~ ~ ' ~~r ~ ~ 1'' ~ ~ ~ ;333 . ~ ~ ~ ••,~,?St • ~lC~ ~ . „ '~y ~ ~~fE~xf~~b.BYIi;~AIFEG~SIRARI~ew+¦,n~e,r~.d ' , ,,;L~~~ J~~', , . j / ~i',/ ~ , I , , . ~ ~'1 i, i ~:t ~ ~ I' .t~1 I I .wr^1 E;.~~, e S .'r.:~ •D ~.;i ,.,~i ~ ~ ~ , ' ~ ~ ~ _.....-n....~~.... . .......~..,.i ~ _ .w~..w., . . . M