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DEATH CT~ATIFICATION
The State of New Hampshire
Thu is to ctrtily that the following is a true copy of facts recorded on the death record of the individual named `
hereon, said record being filed according to law.
A. (Fiat) B. Uifddle) ~ C. !fief) sat
NAI4fE OF
DECEASED R• (~eulart Fet~ale
DATE OF ly°a~? 1>~) (Yeu) AGS tta Yvan Data of Biro
Lut t3iettdaf)
DEATH June li, 1!7! I 5~ Jul~? 1, 1!2?
aiRTHPLACS istt. or Fbeelaa ooaatr,)
PLACE OF DEATH
CITY OR TOWN Plymouth, New Hainpahire Troviience, Rhoale Islam
)tarried D Diwreed ~ 9URVlYlNG SPOUSB (It Wite. Glre 1taWea Name) Soe. see. Ha•
ilt~as F. t3eulart A02-11t-477
Never Parried Widowed f3 -
RESIDENCE State County. City or Town
New Hauspshire Grafton rlymouth
CAUSE OF DEATH
Part I Death was caused by:
Immediate Cause (A) VentriC sr fibrillation
- Due to (B) Careinetoa w1 metastases
Uue to (C)
tledieal certitintioa sisnea B~ Titk Addreee 20 Avery $t• i Date Sisued
Plymouth N. H.
John F. Archibald, l(. D. ! , I June 1!, 1!7! i
I'laee ~ (Name of I.oeatioa ICit~ or Towel (State) Date
Riverside Ce>tetery Plymouth , N. H . June 20, 1!?! -
-
S NTAL INFORMATION IF DEATH WERE DUE TO EXTERNAL CAUSES
Y J'~ , !Gift or Towa? !State) I
? . Place of 1n1ury
4..F,.
~r ' ~ _ IIIa) IDa~I (Year) !Hour)
- Tinto of Injury
- 'T-' Means of Injury
Y~'•
~7,•~~
re. ti f ~:s /-[/y/~ Clerk of Plymouth, N. H.
[ir- r r% C4~
4..! ..fY - Date of Issue HarCh ..~s.. 19 a® .
Y. S. liA l0~77-!OM
65170
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