Burial RecordV&
(Ove:) THIS PERMIT TO BE RETURNED TO AND RETAINED BY LOCAL REGISTRARS WHEB& BURIAL wAA MAO!
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STATE OF NORTH DAKOTA—DEPARTMENT OF HEALTH
DIVISION OF VITAL STATISTICS
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City BURIAL.—REMOVAL PERMIT
Tewnzhlp Date of Death-
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Pall Nes —s �Q� _� /�./ � fOe�Q� so, c 1� Color LjS.2:
Gaze of DeathPlace of Det '
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Place of Burial a4i!-, Cl2G hfedieal Adoadan
y
6emoval to t� VIA—i/7
e
Undertaker Addr License
A certificate of dm1a having been filed in my office in accordance with the L .[ North Dakota, I hereby authorise
the of the body of said deceased person as above stated.
tnariaF us rem..rl
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Dab Land
Township, VHLR
lty
or City—
w
Burial
Burial permib most be delivered by the undertaker to the wabn or other paraou in aha rte d the burial [ebony or and
S
within tend
days amt by the ertee b the local is that district where burial take plate. When the body ie pe be shipped
to be
to a distant t. on carr
pMnt, requiring the aarvice of •common terrier, the body moat be accompanied with a reaplar transit permit.
(Ove:) THIS PERMIT TO BE RETURNED TO AND RETAINED BY LOCAL REGISTRARS WHEB& BURIAL wAA MAO!
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rt IR S T R LC T IO SS
nother form of removal or burial permit is to be used, ..rent transit form. Destroy old forme.
o, dead human body shall be buried or removed without a burial or removal permit issued by the registrar where death occurred.
p, registrar may w- eves burial or removal Dertifuntil a completely filled in death certificate has been filed with him and signed
tT
persons authorized by lato elan death certificates.
th certificates most be legibly written or typed with black ink and completely filled in.
n person not an authorized registrar may issue a burial or removal permit
3
.A. er, this is used as a removal permit • subsequent burial permit meet be issued.
n
.� anal permit issued bye registrar where death occurred should be honored by the registrar where bvri sl is made ezcept
or vnasv nl circumstance. or by order of other legal authority.
� on -observance of these rules will invite legal complications.
':. eis...c........ 28462
This Certificate and Permit must be detached at this perforation and '�eljvered to the person in charge of the corpse.
NORTH DAKOTA STATE BOARD OF HEALTH
TRANSPORTATION OF CORPSE
(Original) TRANSIT PERMIT O For use only by North Dakota Licensed
N* Embalmers
g 15620
CERTIFICATE OF DEATH State of North Dakota
Bureau of Vital Statistics
11-16-26•IDM
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1. Place of Death,,1
u
: Counts ...... ____...._. __-._._.._.._.._..__..... Just e._ ........ ___.....- Registered NO__ .....
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It
e
Towns _. __... ._ _ _ _ or Village ._.. - _ ___ .__ _ _..... or
��// �� �
City__ � ._ _ .. _- No � ._. ---------- St.. -.---.Ward-
_.<� 9/vXY.f'U
I) _ Its ineteq:C
E,
4
It d- ho�apiffi'tfor�ineiitutbn gwe name of street and number)
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2. Full Nam.. `tel`-�+/c�: �� ��. C...._./v.=E'Q� _._ _ __.... .. ...
(a) Residence Na ?ad./"/�"�_ St..._. ... Ward..
(Caual Llaee u[ ahode) (H non-reBident, give city or town and state)
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Length o! residence in city or town whNb death Red - Tears,
m
ec.._
II How long in the United States if of foreign hMb_— ...... ._.. _ _.... Q.._Q_...._--years, ..... ._..____...__._.months, ......
II PERSONAL AND STATISTICTL PART'CULARS
MEDICAL CERTIFICATE OF DEATH
J
orT�—Race i SDIVc9rc�l`M-1-1-9
3 Sel1 l4. Color e ai Wid �
toe�or
�a
Denih,
of Death (mday, ^ r V. 19_ys_
'
l Y `-z
J'
".- _ate
_4 '-0
Se If Married, Widowed, or Divorced
HUSBAND of�t
1 HER BY C TI - vt IOeaased from
~ tA7l
.:
(or) WIFE of
leer saw h�eyv. ve
that 1 la ali
and that death occurred, on the date stat at -..... _-...... m.
S. Date of Birth (month. day, 1d ear
The CAUSE OF DEATH* wan follows:
__... ..
T. Age years Orth ----�
Day£ ,(f leas
il day
._.._._
b. Occupation eeemsed
_.._ .._. -..... . _ -_
y
of r famthtl
(a) Trade. D or
f..
a
C
m
particular kmd otwori. ._._ .__ ...
(b) General nature of industry,
business, or estabilabment in wh ci
... dur on
.__ _.- ( ) - ._Yn. __moa. ,-.ds.
CONTRIBLTORV ,
m
emDloYed (or employer) _._ __. _......
!i
(Seconda7) get
_ (c) Name of employer
'-'- -_.__.:._...(duration) _ moa. _,_._da
18. Where was tliaate contracted
If not at place of death I _.G� _
_!)-"'L---'---^--
Did an operation precede death Date of_ .T_
-_
9. Birth hates (city or town) -
(State or Country)
t
1D. Name of Father
L
I Kci
Was there an >utopry7 _.........
What test confirms Ia1 _.. _-
-"-- -
y-,
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11. Birthplace of Father (r��]ttDyy or town)
(state or Comtty)
c
W
lop
(ASitlatlne)a) M. O.
G
�
Qr1ZMaiden
Name of Mothery/
the Disease Causing Death, or In dea49 trOID Violent
Causes, state Q) Means and Nature of Injury, anu f2) whether
6'State
a Birthplace Mother (c town)
E
of oY
(State or Country)
Accidental or Homicidal. (See reverse aide for Addlllc.+a! apace. )
19. Place of Burial, Cremation or Removal
Date of 1urh1
c
14.
Informant I
:i (Address)
1e
E"
15.
p, Undertaker
Address�i
' Registrar.
PERMIT OF 1,OCAL BG, -'RD OF HEALTH
This
Permit must be properly signed and with Physician's Certificate presented to Railroad or Express Agent or other
Common Carrier before body can be ship(To auto transportation.)
-�include
.__.------of...__..:..._... - . ---.__..__.._.---_-_ .............County of.__......--......... �'.".�._____.._....-
__..
or wnship / _
�C/�ity
�1
State of..._... �1._.7..._ .(,-_...—...oa the .... _..._..p.fl__-._4_ ------- __-------- day of-__.._!!._—__.
Permission is hereby given to remove for burial._......-............ ............... _...--._....._.._....-------- -----
isthe County of --- 7..... _......--..... `.—.._---._.. State of. ------------ `.'.`.�...... ----.._........----------:._._..--
the
wbo
-._--�o------ '_....f . s �.........._.....__._...._...._........._-_-......._.__...._-__.._.._-_--*---._....-:_.._---
diedi�.--_------_--_-----...County of--__.. state of.......{_.._-�r1........-........ _ 2-3
on the... ---....----
body4ofd
day
p r 3
of_....--....._,19�Aged..._..1l.._yea18.__.___._'-......-_.-_........._...months.._: �-��._. _.__...._.......days.
being...... _... _.......... —.__._--- which is a__ ........ ..... _.............................................. Disease.
�y ,�rr'� /� - -. Communical _. or non-wmmunicsble
/u
To be accompanied by.az. LfJ _C1E3..__- .._._..�._...__..._._..._. as escort
Rule 1. The transportation of bodies d f amajl z r bu Ice
p - ion' p gue from rye state is absolutely forbidden.
(If City or Town, affix
(f//neo
Corporate Seal) Signed..._._.__.._..__... _ .. .. .. .... ... .. ._�g�...-.--__..___._._._Eealth Officer.
This Certificate and Permit must be detached at this perforation and '�eljvered to the person in charge of the corpse.