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3~~JO"~ BOONE COUNTY DEPARTMENT OF HEALTH ~ ~
I LEBANON, INDIANA ~~~R
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I~ ~ } } C_ERK C:RCUiT CCU?T
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THIS CERTIFIES, chac according co che recotds of che Boone Counry Deparcmenc of Healt6~~ 3 42 PN ~1? -
Name t'al~r p'rtd~~ielc 1~..e ~~v~~ ! -
ll+~'~_ at E S_ T.,
Died on
1TfMEl
Place of deach A~a I~
1N05?ITAL OR ADDRE551 f
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~ SEX MARRIED NEVER MARRIEO AGE~~~w r¢wwsi IF UNDER 1 YEAR ~F UNDER 24 HRS. ~
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~ WIDOWED DIVORCED wo owrs Hour+s w~M. _
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Immediace cause of deach given was C~~~a~~ - ~
ATTEND.VHYS. GORONER MEAITM OFF.
Certlfied bq DY'~ rh~'t2'1 ~a 0~ ti~dl~~ 1~ D~ ~ L~batlaa~ Ind. Z' .
(NAMEI IADDNES51 (CMECK ONE1
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Plac~ of burial or removal
(CEMETERY) IADDREfS1
Funcral Direccor ~ ~ IOd~ t
~ . iNAMEI IADDqE851
~'dtt Of BUii1~ 11~~~~
~ Recotd filed 11~1Or7'~ Book No. Page No. ~
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~ I BOONE GOUNTY HEALTH OFFICER
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. , - . ~ ~ v 1 . This cerci6cate issued on F'~~ S , 19~- ;
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