Death Certificate. - (Where aeceessm . ..
4. USUAL RESIDENCE b. COUNTY Antonio-.
O DEATH: STATE OF MINNESOTA e. STATE Meeker
Minnesota R TOWNSHIP
Meeker c LENGTH OF c
I STAY in 1 b. Dassel �—
(�g g `—POST Litchfield c Greet eddrm) d. STREET ADDRESS
AOL ORS m M1osoi4l or imtimion, yr Dassel
TION e, IS RESIDENCE INSIDE CORPORA LIMIT57 I I. IS RESIDENCE ON A EARN?
OF DEATH INSIDE CORPORATE LIMITS? YES p NO O
p YES ANO Ynr
4 NO O I 1. DAA Month Dey L
DEATH April 19 1966
Fd'•) Otto AFlsohkOW sky 19. AGE (In seen IIi UNDER 1 YEAR R UNDER 41 HRS.
Isa t nhdey) Mowhs I Den I Hou. I Min.
I6. COLOR OR RACE 17. MARRIED p NEVER MARRIED O I B. DATE Of BIRTH 87 N
DIVORCED ❑ Jan. 1 1879 114. CITIZEN OF WHAT
')ltB WIDOWED R I 11. BIRTHPLACE (SNu or bre4� countq) COUNTRY? m
B I tob. KIND CK BUSINESS OR v
OCCUDAIION (Gass 6�d d work IND(15TRY D S 40
eoo d wwfx9 Ide. <ven it rxired)
Gene Fannin Minnesota
IT 111. SM) %S NAME p
^'S NAME 1136. MOTHER'S MAIDEN NAME h><�s-k 7 °
Jos hi Bose.—__= a
Anna NI'S OWN SIGNATURE AODRF55
ZDS Buschko�+s I6 SOC SEC. NO 17 lNF
DECEASED EVER IN U. S. ARMED FORCES? %/ ,,i / ,:�, J�. l ['a3 P
m (11 To,
!we wx or detx of senr<J I — 8-88 _ i INTERVAL RE1WE N
no-- -----
ONSET AND DEATH
SE DEATH (Enter only en< uwe Per base for W. (b). end (<))
I. DEATH WAS CAUSED BY: p S C U IL`7 1' � C C i CIP- III--- i
IMMEDIAIE CAUSE G) t L '� n
• nan. A � DUE i0 (b1 J e era 1 ed r i� v sc le vco------{--
exe
.It ro
1 ,he seder. ,/ e S
rens on Lne DUE TO <c) 7 19 WA5 AUTOPSY i
pERfORMED?
T IL O1HER SIGNI ICAN CONDITI TRIBUTING T DEATH BUT NOT RELATED DIATE CAU—SE IVG NEI VG NE NO
YES O
N DART t0)
E OPERA. 119b. MAJOR FINDIN S Of O RATION
NT, SUICIDE OR HOMICIDE. lSMCIfY): I
4Db. DESCPIBE HOW IN1l)RY OCCURRED. (Exec rorme d mrvry in Den I or Dm 11 d rto 18)
OF How Morrlh, OM. Yew
• yo pUN1Y y
P' m' INJURY (r L. in w show 1TI
461 CITY, VILLAGE OR TOWNSHIP u
40<. PLACE C etc )
CKC(1RRED home. krm, wary. are<e onme bld,
�AT G NOT WHILE OI
AT WORK
/ — , end tl.e I I<N w.r rhe deemed d.e o u
end ro rhe Inc,d my Lnowledle. Fro. the .wx axed. a
wended dye deceased I on d.e dwe awed ebore 44c. DATE SIGNED —
_dr demh ocmred < _ I440. 54 ,/ '.0 /� m
CREMATORY I 43d. 1pCALON r
or county) <kw<)
cemeteryCArver ttiog oto
SIGNATURE Of
MORTICIAN OR fUNfRAI DIRECTOR
ADDRESS m
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