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Death Certificate - Davis, Samuel C_5/4/1973, 'i F K � t.� '�•iATEMENT"OF'DEATH"BY FUNERAL OIRECTOR . .• �'> - �. \OT[GE yR'hoe�•er makes � wses to be made.an� false sta[ement or repres ' �on of a material fact fcr use in ,�i �.- ��;" t?± �� . delertnining a.right lo pa,vme_ .+�hnder.the Social Security Act is subjec[ to not�e=lhan a 51;000 fine or 1 Sear of v- _, w •.:, - � . � - . �., . , . y, �¢ ;imPrisonmmt.�orboth. ---- - --. . ' . . '�-" ;� . � . . , . . ,.. .....�..�-�...__, _ ._ _.,. . _ _ . .. !'�r• " ' 1. NAME,OF DECEPSED � � - . �2 SOCI�L,SEN(iiTV NUMBER _. � `.'�'� - 3�mue1 C. Da_vis*, `��. - _ � ��:'.'? ' 3. SEX 1 . . •�. DATE OF DEATH OF DECEFSED �\ . }+.°•. . . .. . . . , ��` . ��-._' ' " ' � �M4LE 'n-FEMA�E � � � --�� y-27-1'�73 • k : • ' �« .��•` � T 5. NNME AND <DORESS OF DECEASED'S NE%T OF KIN. fIF NO RELATIVE'S ADDRESS IS KNOWN, ST�TE NFNE AN� ��DRESS OF ,��' �, �.-�S �' J� PERSON WMO ARRAHGED FOR BU9IALJ . -. F - 1.'.'-� �� 1Q N�ME OF NElti OF RIN PEI�TIONSNIP ' �i �� 1 � �s J . �,� €t` " - vrs.Eliz��beth Davis ;li"e = ,�� .'_� . �Z ♦oDaE55 (FO. end5treet, P�.O. Bo+) `9rt,rf � ¢ . . . � � . . i?i` � 351�3 i".ary ::ve. Fark City , � �. �_ � � W CITV 6ND STATE : ^ ItP CODE TELEPHONE NUMBER OF NEET OF KIN . f.'- � � . : . " ' " ' ' ._. .. �(7leveileDle) . ., .. _ . . .... . _ . � , . � . `„3U'.{anarl� T_II1C1015' v00cK � � .r.•.. ' . w • ' ' ' i � N _ . . -. . _ . - Y a ' ' ,�_� "� �, J i imrrby ecai(}' dint 1 nm an au[iicr:zed funcrul direcwr �and-prepared-:or-Sucia;� ur `x,ried : e Sod}• ot-::c�pc:,cr. - +�:? - a named abore. [ underseand chis scaeemenrmsybe used in conneceion�w-ich�an applicacion.for social securint,_,,,,,., �.- ,'y.:� �, benefits.' _ . .. ,. . � . . � • ._ '{��~� ' . �_' NAME OF FUNERIL DIFECTGR OR F1RM SIGN4TURE OF FUNEFIL' D�RCCTOR OR GUTHOR2E� � • (t"• - � ` . . � pEPRFSEVT�:IVE OF FIRM . � - ' ' . . • a)S . . . �. . - . . i : "^ >` :; . :_� . ,� �.. Colvin �- �on •"•:ortuary � . !�� `� �'�-�-•-�- . •DOwE35 (No. and Sveeq P.p. Boi) ii .. 4?5 Pi.;.air. . . .. _ CITY, ST4TE."�ND 21P COOE. . � Pri�cet'on,�Indi^na 17�?0 : or se Only — DO NOT WRITE IN THIS DO Processeci. .. ...s. . � �n��e/ FOFM ��A; �i.C�.u� AY�)«T'.�. 1 i3an_ . . . ' :=rtner �. - TELEPMOYE NUMBER D�TE . Slz-385-52?1 _' 4-30-1973 � ,' , \1' PH 6IR CH .•, SF . KC DIO ^ -.. � - - .' - • ' ' � � � . �- • ',i - .,. � t ! ./ - _ - � � \ l . ♦:�'l�..s Y"- _.. •.. . •._ _L__..:i��_� ':) � .f. .. i .-v: