How long Resident in the state. | - Place of Death
- Cause of Death
| - Complication
- Duration of Complication
- Duration of Disease
|
40 years | - Jefferson City Mo
- Paralysis of Heart
| - Instantly
|
- Place of Burial
- Date of Burial
| - Name of Undertaker
- Place of Business
| Name and Residence of Physician Returning Certificate |
- Jeff City Mo
| - Jos ?
- Jeff City Mo
| A. C. Davison Jefferson City Mo |