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Death Certificate - Davis, Jack Lee_8/23/1973� J� --�_- - - - -: - - T- - - - -- -- - - . - - � RECORD OF DE:1TH . - GIBSOI`T COUI�iTY DEPART\IENT OF HEALTH . :. . -. .- � . �.. ... .- PRINCETON, INDIANA . . . . � _ THIS IS TO CERTIFY, that our records show ,T3nk I„nP navis " died -� �-- 11� �.:��6%�at�'I .S�A?R"(:i}�.��l:an��i+n�. Prinr.at�n�' Tndiari3 - . � � . .. � -.. � - - month - � day : year,? �� . hour. of death; . ,'� : ' ; .:". � . . : :' • . ".. � treet, hospital, rural , ,_ _ � , - - - � � s _ �; .. � _ . . . . . .. - .. � . Aee-at Death �7 ' SeK �"al ° Color ��dh� te '�� - Marital Status ��`3rried `� - - - ��-" - .,. . -' ' . ...write �chether mazri=3 or �iagle - ' . _ � ' `-„ " . . ' _ ' . _ .. _ . _ _ " _ . _ " - ' .' . . . - . . ' . ., ._. _...� .,. ..._, ..... ..__ . . . ..Y:; . , .. . . . , . . ' ... �. _ _� _. . . '� � . . .- .- ' . _ . . _. ' " . -... �' Primarq cause of deatk given wa� Aiassive' hemmora,ze' .. _ __ - . -- � - . - i:-�' - � - -.• - -- - - . ••_._ . _ _ . - . . : Signed by_ - $,� r Printr�Tl� (1_ .. -• Prinr.�t�n, � Tnd. �° . . . . : . . �',.,:: physician or coroner � : ,.'. . � 2ddress . . . . ... ' .. �-' ' . . _._.., - .. . .:.'�:.: . _. _ . . .. . . _ : _.- ,-"' . ...-'._. __. - ..._ �._-•'-' -_.' -' •"., .. ' -. - . . ._. -.. - . . . . . . ..: � . - .. Place of burial or removal Fr3ncisco Ind. �•- T Q n� ^AmPt�r:r - . . _ - — . • name of eemetery . _ . . . � address � � . ... . . ` .- 'Date`of burial O.D.��fiarris P� "Sons ' ' ' •' Petersburg, Ind. " � ' � _ � - � - � �- � � Fh�neral�Director . � �• ' address " • � : - - - ' � - � , �� ,� . _'_. . • . ' : . . . " . . . . . � - . .-. . . � � � � � � h z . _ . . . _ . . . _ . ...f=r,�� Iti,� �, _ _ . _ . . _ ._ ' _ �; ��" �, �,. - � ; >�,,• ' ; � ,� : _ � : • _ . . , . - `; r'sEA'.� i , _ s;ga , � , � ; �. � �� ! � � � � � . . � ` . ' ib on n e Com sioner ' - � � -�).�1� •;� �.�� . , . _ . . . .'�� ..:' . . .. ' -- � -.. _" . s .:�' .-;.�;°�'.,. � _.. -Princetori,;Ind.' = � • R/23/73 ' ''�� :: . _ . . `�� l� . . � , . . . . . ' address . . . . . . - . � date � �� ; � � „t �, l ' . _ : . _'.'. . ' . • R/21 /E�7 Re�o*�l'Nl loca�llv, in book No ' 7 page No '18'i VFiledi . - -: -. :-_. _. __.� -_• _ _ .. _ _ ... .. . .. __ _ . '.. - - :.;_ .�: - - -_ - . _ ; ._ . . _ . • . ' __ - - . :,;_ - . -.- - . - � ---• - -- --.. � .- _ -. . t :. . . - ... __ ..�:: _ . .._.