Death Certificateieltiii� li�rnii dEn'i'u, txlfr " r.
Section of Vital Statistics i
CERTIFICATE OF DEATH
II 4. USUAL RESIDENCE (Whore de«ued h. d. II imlrudlon: �
b. COUNTY
STATE Meeker
b.
(II rot m ho+Mlel er Iminmron. 9wt u«o .w.•,.. 1
OR DaSSel - •�
" }?eeker Count Memorial llosnit < g RESIDENCE INSIDE CORPORATE LIMITS? I E IS RESIDENCE ON A FARM?
)F ATH INSIDE CORPORATE LIMITS? yES][U NO ❑
❑ YES IXNO Yea
NO OI— DAZE Month Dw '
DEATH sT)1'11 2 1Q�G
Josephine 3uschkows
ATE CIF BIRTH 19. AGE lIn •ser+IIF UNDER 1 YEAR IF UNDER 4a HR I
16 COLOR OR RACE 17. MARRIED NEVER MARRIED 0 0 D 1m b�nb85 Month I Dep I Hour+ I hhn. White
WIDOWED 0 DIVORCED 0 I T1ov. X1880
112. CITIZEN OF WHAT
I tOb KIND OF BUSINESS OR I 11. BIRTHPLACE (S«« or fo«r9^ sou^"•) COLINIRY> m
,I,UDATION lG•< brd d wort INDUSTRY U ccl u
l d worbn9 Lle, wend «urM) of
Cldn home Minnesota
�yi'p 111. SPOUSE'S NAME `' u'
NAME 113b. MOTHER'S MAIDEN NAME _i URCL'l iCC1$I�
K_ Otto ___ __
i'Kelm. M<Ltilda Kotlin __ _
I; FOR ANUS N NATURE — FADDRE55 a
.ASE�N U S. ARMED FORCES? 116 SOC SEC NO �M
(11 V.I. yv< wu or det.+ of I IT �_� / J //�
r Logi for (J. lb), tad lA) NSC I AND DEATH
Of DEA H (Enla onl• on< s.u« a
DEATH WAS CAUSED BY: r^ C .�. I n -.r�C� hrl /'•1
IMMEDIATE CAUSE CJ A e-61," -U' I a r
((/�, le�z I�-learn-
em. fl .m. DUE TO (b) vy m1
'm on I.n< �e��os�IC rRJ I. 1-1 C J _---=_J __ �-----
me Tel (d ----ra :c... cniTrc �Ai1SE GIVEN 119. WAS AUTOPSY
S IN PANI IW �� I
f F RA- I lob MAJOR FINDINGS OF OPERATION VI''
N
CIDfNI, URRED(frac. nera< d mrun in Pm I' DM II d
SUICIDE OR HOMICIDE. (SPECIFY): 12%. DESCRIBE HOW INJURY OCC. n.w lB )
I&OF
H., Monrh, DIV, Y<rt —
LAY
--- SIA/E r
-VILLAGE OR TOWNSHIP COUNTY
JURY OCCURRED 40<. PLACE Or INJURY (. e. tad. CITY,
A1C NOT WHILE OI hove. fuw. lecron. yr.a oN"; Wdt,
AT WORK Z
ni I engirded the deeensd I t
M end th.t I bn taw rh< dcct.s<d Jwc
L wl<dfey lrow the uaa need.
t daeh occwred t won tht da< weed ebeve end I..%. ben d wr no_ pyc DAZE SIGNS D
NATURE ( gie w I.) 44b. A 5S
.CREN 43b. ATE 43c. NAME EMETERY OR CRftRxsJ(�( !:innea
�`�`) I qr. it E a CheLnh:laaen t C>• I
AT Carver `
6 SAN O rU
RAL DRfCioR ADDRESS
IV In NY 145. GISIRAR'S 51 . w IuRF a �� 46. C�1�1111RE Uf MO419' NE `
i