Death Certificate - Potts, Emery L_2/8/2005PIKE COUNTY �
DEPARTA�IENT OF HEALTH
PETERSBURG, INDIANA
LOCAL CERTIFIED
RECORD OF DEATH �
7'his is Certi(y, that our records sho«•
died � 1 � al_
A omn Y �2er 1
Age at Deatl� �,5� Sex ���� Color�.�]�—
vers
.M1
Primary• cause o( death given �vas (� L'� ' �-� • /
LJU�k..�i"n/� [�'L� 6�J� lr l.
Signed by Dx \y • I� ` ° �X i � � �
ysinan or m `
Place o( burial or removal —�•h� a� m�', �-`"`^"
` (� \ �'j
Dateofburia ,. °n�•."U�='' ��, 199� \ �A-��! ��!
Signed � � �� � � - . � � Registrar
( �
PETERSBUjiC, \DIAi1'A ' `� `�� � '" ✓�i a - � I - 9 �_� I
/ c�
NOTE: Recorded locally in Book No. `� n Page No. � � C7—
SEAL
FEE: 31.00