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THE FACE OF T H I S D O C U M E N T HAS A,COLORED BACKGROUND - NOT A WHITE BACKGROUND

C O M M O N W E A L T H O F KENTUCKY Statu File N«

Form V. S. 1-A
Department of ilealtt) ItogistrarN Ni
DEPARTMENT OF COMMENCE
UCUEAU OF VITAL STATISTIC*
su. A Bureau of the Census
.SO.5 CERTIFICATE O F DEATH

Itccbtration District Xo._ iP gJ^-Q Prin.itry Iient-.lratmn District No U.../...,/ /

I. PLACE O F 3 E A T H : 2. USUAL RESIDENCE

o 9 2 (a)

(b)
County

City or town ^^•^^Li (a)

(cj
State

City or town.
(b) County.
JL
(If outside city or town limits, write RURAL) (If outside city or town limits, write RURAL)
•K< (c) Name of hospital or institution:
| (d) Street N o . _
. 2 ft. (If not In hospital or institution write street number or location) (If rural give precinct)
Si" (d) Length of stay: In hospital or community..
(years, months or days) | (e) If foreign born, how long in U . S. A.?
«*o
r
(0
o
3(a) FULL N A M E - Jl AJ*SI^<-^I~AJL
' - 3(b) If veteran, 3(c) Social Security MSSilCAL CERTIFICATION

yS s Name war No 20. DATE OF DEATH

* ^ 6 ( a ) Single;, widowed, m a r k e d , !

hi &**M divorced—
21. t h e r e b y certify that I attendtfq the deceased from.

O ^ ^ - M l j $ ~ - \ i U J - . " > « • i
last saw rv-tv.alive on
SHU S(b) Name of husband or wife, \\*?0^&AA?UAs

a^- hi$
(U^l*<J*_ / O \lH(_ and that death occurred on the date
s<->
*> "i S(c) A g e of husband or wife if aj^ve.
ted aboVe * * . / A ' / * J&L M.
••ai 7. Birth date o f deceased.
(Month) (Year)
I m m e d i a t e * * * ] ! * } of death /j , U
(Day)

I. AGE: Y*ws Monihs, i Days If less than one day a

-«•
In In
^\£3
h£e>asLt Z' -SSL
P o, J

[ 2 2p.
J.-J
7.

10.
Birthplace

Usual occupation -
-8f
z 2 1 =E
«—^ 11. Industry or business.
I»ll J «r t/U»|l|«J»1 i —„„ _ jm .- .- ' —
•
Other conditions
(Include pregnancy within 3 months of death)

53 e
Major findings:

§11 < 113. Birthplace Of operations .

= £2 W I 14. Maiden name Of autopsy

H a .-
>*S 9 J 15. Birthplace
>>-3-
•J"a.S 16(a) informant's own signature. E^A^y^dkSi 22.

(a)
If death was due Jo external causes, fill in the following:

Accident, suicide, or homicide (specify) _

Z. j8' ft
5
(b) Address / £ (b) Date of occurrence —, ••
< 8*
(c) Where did injury occur? in or about home, on farm, in industrial place
17. B U R I A l - C R E M A T I O N , OR R E ^ O X * 1 -
• Date- in public place?
(Specify type of place)
S-SO a. 18(a) Signatuije^f funeral director \ * ^ J I —S—7 Whilee at work?
work?. — (e) Means of injury

a (b) Add 4-1$ — 23.

23. Sig
Signature
5ig» -Jtl KW—/ ,fi
(M. Djjr other)
z
received registrar) (Registrar s signature) Address /ZJLJUUUL Date signed X " / P ~/tT~/

THE B A C K OF THIS D O C U M E N T C O N T A I N S A N A R T I F I C I A L WATERMARK HOLD AT A N A N G L E TO V I E W

I, Sandra J. Davis, State Registrar of Vital Statistics, hereby certify this to be a true and correct copy of the certificate of birth, death, marriage or divorce of the person
therein named, and that the original certificate is registered under the file number.shown. In testimony thereof I have hereunj/subacribedfmy name and caused the
official seal of the Office of Vital Statistics to be affixed at Frankfort. Kentucky this __ 0\UlfAS jjPjfafljfe/jk&tf-, 20 0<Q fl/

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