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ATTENT*IDN STATE The Social` Sec�un a y't r ��v- `'tea •�-''` `` -- ,3Boonvllle•-�N,- N• ,t,., y
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pu(SB I(Qs sla(uiory.responsblggty Dls<ID 8.,5 INDIANikaTATE DEPARTMENT7OF4HEALTH �' T`` '``'SEP 1 8a207�,
s volun ary and this WJI be no Penalty IDr reh.re l - z tr».a �' ISsued '- 1' S..rxy :Ivy,
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NN Local ND W. OERTIFICATE`OF,DEATH State No �-: . +1
5lI W�.` T,.. REGARDS IN THIS SERI.S ARE CONFIDE-AE, P;ER IC i-Mtl0 f• ,fttr .Ln ce y __t i r,
•'I DECEASED NaYERtF .4M.oul..0 V �'�? i 1 SEs \' \\
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YPE/PRINT4 0 ED IAUSIa , N .4 1 fs 5. L,MEO DEaM se oarEOFDEA-L o anti
k a"=1Ns`` 4. jrMJames Leonard Sm(th " < 4,-,-_ '"_ 04 ]OrPM ,Sep _mtier 1 O. ' ii t17< �
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