HARGIN RESERVED FOR BINDING
WITH UNFADING INK—THIS 1’8 A PERMANENT RECOR
STATE PRINTING DEPT-
D. Every item of informa-
PHYSICIANS should state CAUSE
may be properly classified. Exact statement of OCCUPATION is very
carefully supplied. AGE should be stated EXACTLY.
OFDEATthhmtemsoihatlt
important.
N. lid—WRITE PLAINLY,
flon should be
Oregon state Board of Health
Division of Vital Statistics
Standard Certificate of Death
sum or OREGON
Stat. Filo No. ...._«.............. A
Local Registrar‘s No. “Arm...”
1. PLACE or DIAI'H:
(a) Count!
l
(b) any or gown \\
WI! outline on; or can a mum
(c) Name at hospital or inautution:
(I! not in howim or institution writ. most number or looatfin)
a. own. I:
(cum.
INC! 0" DICIASID:
(b) County
(c) cm or town
(4) Strut No.
woman ormumm tale
(1! rural aim location)
I. (a) Binnie. gamed. i'na‘rrledI
divorced ....
5. Comm
Box raca
l. (b) Nam. 01 buaband or wiin O. (0) Ana 0! bush 0 or wile
" i! vo ms
rim? 1: / 5
D: ) Year
"ml Lum__...__w
7. Birth date oi ‘
'"EL"K&E1”"§Z§. Tum. nm uloaailnnonoday
‘
i
‘7 H" 3,, 3.5
I. lirihnlnco
(Clinton. oroo r
u. Ulnal occupation L
11. Industry or bnslnu .....
g 11. Name
3: ll. lirlllplaeo ._....._____.____.
(City. or oounm
a it. Malian name
it. Birthplace.
o
I (cw. ion. or county)
it. (n) Iniormani'l own
(b) ran
11. (a)
(
,_ r
(b) Date thereof
Burial. emotion. or mull (
(o) Pia : burial or cremation
a ,‘ a a . 0‘
in. (a) Stanton oi {Eff-a1 ' t
(b) Adana:
I
it. (a) (b)
(Duo “mind loch Mint) (mum-uh mum)
ulherebycertilyihnil “
" ‘thel
(d) Innath oi nay: In homital or institution é
m mu community m “m ‘5 m" (a) 1: foreign born; how long in u. 8.
Ad _.__.____ yam.
learn, mom! or (tax!)
‘5 ‘ MEDICAL CERTIFICATION
3. (a) run. NAME ___£‘_‘!=i:i4__
I It. Daio oi «loath: Month (in:
a. (b) flvoieran. 8. (c) Social Scout-1w "a E Q hour mm. l
name war ..__... No.
tram
19 . to
on #2..
and he mated above.
.19112:maunnuwh.£u.mve
. “Maud that death oecmed on tho date
Duration '
Immediate gauna g dill
unto
n ‘ L E EM
Dun to
oihar condiiionl PHYGIOIAN
(lnoluflomvilhlnamnmofdoalh)
Major iindinu: Undorllna
01 our “ tho cauno
to which
death
ahould be
0! auto»: ~ charged
manually
I8. I! dull; wan dna to axiom-l cannon. illl in tho lollowlnn
(0) Accident. mioido. or homicide (m)
(b) Data oi occurrenco
(c) Whoa did inlury occur!
in public plaoal
(Oil: 0 town)
(4) Did injury count in or about home.
(County) (State)
n arm. in man-um place.
(Smelt: in. of Dim)
(0) Mom oi injury
, OCR Text: HARGIN RESERVED FOR BINDING
WITH UNFADING INK—THIS 1’8 A PERMANENT RECOR
STATE PRINTING DEPT-
D. Every item of informa-
PHYSICIANS should state CAUSE
may be properly classified. Exact statement of OCCUPATION is very
carefully supplied. AGE should be stated EXACTLY.
OFDEATthhmtemsoihatlt
important.
N. lid—WRITE PLAINLY,
flon should be
Oregon state Board of Health
Division of Vital Statistics
Standard Certificate of Death
sum or OREGON
Stat. Filo No. ...._«.............. A
Local Registrar‘s No. “Arm...”
1. PLACE or DIAI'H:
(a) Count!
l
(b) any or gown \\
WI! outline on; or can a mum
(c) Name at hospital or inautution:
(I! not in howim or institution writ. most number or looatfin)
a. own. I:
(cum.
INC! 0" DICIASID:
(b) County
(c) cm or town
(4) Strut No.
woman ormumm tale
(1! rural aim location)
I. (a) Binnie. gamed. i'na‘rrledI
divorced ....
5. Comm
Box raca
l. (b) Nam. 01 buaband or wiin O. (0) Ana 0! bush 0 or wile
" i! vo ms
rim? 1: / 5
D: ) Year
"ml Lum__...__w
7. Birth date oi ‘
'"EL"K&E1”"§Z§. Tum. nm uloaailnnonoday
‘
i
‘7 H" 3,, 3.5
I. lirihnlnco
(Clinton. oroo r
u. Ulnal occupation L
11. Industry or bnslnu .....
g 11. Name
3: ll. lirlllplaeo ._....._____.____.
(City. or oounm
a it. Malian name
it. Birthplace.
o
I (cw. ion. or county)
it. (n) Iniormani'l own
(b) ran
11. (a)
(
,_ r
(b) Date thereof
Burial. emotion. or mull (
(o) Pia : burial or cremation
a ,‘ a a . 0‘
in. (a) Stanton oi {Eff-a1 ' t
(b) Adana:
I
it. (a) (b)
(Duo “mind loch Mint) (mum-uh mum)
ulherebycertilyihnil “
" ‘thel
(d) Innath oi nay: In homital or institution é
m mu community m “m ‘5 m" (a) 1: foreign born; how long in u. 8.
Ad _.__.____ yam.
learn, mom! or (tax!)
‘5 ‘ MEDICAL CERTIFICATION
3. (a) run. NAME ___£‘_‘!=i:i4__
I It. Daio oi «loath: Month (in:
a. (b) flvoieran. 8. (c) Social Scout-1w "a E Q hour mm. l
name war ..__... No.
tram
19 . to
on #2..
and he mated above.
.19112:maunnuwh.£u.mve
. “Maud that death oecmed on tho date
Duration '
Immediate gauna g dill
unto
n ‘ L E EM
Dun to
oihar condiiionl PHYGIOIAN
(lnoluflomvilhlnamnmofdoalh)
Major iindinu: Undorllna
01 our “ tho cauno
to which
death
ahould be
0! auto»: ~ charged
manually
I8. I! dull; wan dna to axiom-l cannon. illl in tho lollowlnn
(0) Accident. mioido. or homicide (m)
(b) Data oi occurrenco
(c) Whoa did inlury occur!
in public plaoal
(Oil: 0 town)
(4) Did injury count in or about home.
(County) (State)
n arm. in man-um place.
(Smelt: in. of Dim)
(0) Mom oi injury
, Z ArchiveInABox,Car Collections,American Muscle,Chevy,Test upload 2/3/26,Test upload 2/3/26 1, Test upload 2/3/26 1
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