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CERTIFICATION OF VITAL RECORD h
reel, factory, office building.
27c.
REGISTRAR=
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CONDITIONS
IF ANA.
:WHICH GAVE
RISE TO
IMMEDIATE
CAUSE
UNDERLYING I AST
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CITY. TOWN OR LOCATION of D E
74 Idaho Fat;
SI ATE OF BIRTH (11 no nUTA
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sOGIAL' SECURITY 4(UM4
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1111'10 ,I Iii I i1111 1 lillh V 11111i11' 111 11 Ull p I! II DATEI;I9F D AT l l fll! y 1
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to Irth DER YEAR
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16111
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DATE OF BIRTH IMO, Od',
1 a 6 nA v 1(7 IGbuN DF DEA
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1 I Name (If r f,, ve st 4e pn �rmb4 rr
C rr MARRIED, p 1 III I II I I III IIII I II OP ErrIgr. R 1 Inuatmny DOA,
IQ I 1 I� I�I I 111 mil, 6 R INST. Ind¢
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t� Ni OF WHAT 40 I RIED SURVIVING SPOU�`E Ill wile, l 7I
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STAEET-AND NUMBER
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CITY, TOWN OR LOCATION
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V�'1 BIRTHPLACE MOTHER MAIDE 1
BI RTHPLl
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Jane ligeekee
MAILING ADDRESS STREET an R F.O NO. ilb.
CITV OR TeWN 6tP
111 "IIII Box 2 2
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1 Rf 5 7 Idaho Falls,, Idaho 83401
II�� Ill E CEMETERY OR CREMATORY NAME
LOCATION CITV OR TOW
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ANY ALTERATION OR
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Tfiisis3 troe ar�� Drrec} rs �bductiorl' Iltbe tl0'cument ofli'ci lly registc d and placed VIII
on tits w,fh the A HQ CEN, (VITAL STATISTICS AND HEALTH POLICY.
I. 1 V fill
i i
DATE ISSV.
This copy Is n va unlass p p red, on engraved border
displaying statal�se and si pa Urel pf 108 Fegisfrar
1ii ,1„,, !Ill 1
IDS THIS CERTIFICATE
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REGIST AR (Mo Day, OY y
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Interval between ousel and death
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