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Gustava Merle Jones
Page No. Date of Death Hospita I Name City ge Place of Death County Date of Birth Birthplace Spouse's tiaiden Name Marital Status Occupation Residence Mother's Maiden Name Autol)sY__--- Father's Name Veteran -----L — — — — — Social Security Number Physician Services --- Minister --- Cemetery Pallbearers: Time —Date vocalist t Burial Date Brothers and Sisters: organizations! �}CY page Nu____---- Date of Name P Y —Hospital Ile v a r Spouse's Maiden Name Marital Status Residence 864.1 H 6 7 t 1,1 A 0' Occupation -�,Je lilt Mother's Maiden Name Social Security Number 0 "i 4 *� (I -, 1 1, , 5 veteran Physician Minister Location— P Burial Date PuUboa,ma: Chapel Z q n" '' .,_. Glendale, Az Ph � -- 6 D L n» n | � > Lqle ��-'---� 2 Fren:�- /uzara.i*. 112 Brothers and Sisters: VO sw _2! REGISTRAR'S STATE OF ARIZONA FILE NO- 15705 TRANSIT COPY DEPARTMENT OF HEALTH SERVICES — VITAL RECORDS SECTION AGE OR COLOR BURIAL -TRANSIT PERMIT SEX white (This copy must accompany tion 89 A BStISI tion A S B. MIDDLE 2, Female s. E NAME OFJones Merle N T DECEASED Gustava A. TOWN OR CITY 1. PLACE OF DEATH Marico11a Ariz�— IOENTIFICATtON DATE OF DEATH phoenix _ BY COMMERCIAL CARRIER, OR A DEATH FROM CERTAIN DISEASES OF 5 t r 22 198 6. MOVED DECEASED CAUSE OF (MUST BE COMPLETED IF BODY 19 SHIPPED OUT O TE' C. CITY AND STATE DEATH B, ST. ADDRESS Hyperosmolar State A. NAME AZ 85301 7• FUNERAL HOME Glendale, BURIAL OTHER 24 N. 59th Ave. DATE SIGNED MANNER (SPECIFY) 9. Chapel of the Chimes 79 El CREMATION LINER D EC OR 5 SIGNATURE 11 1,Z-•23'-87 AND REMOVAL C. CITY AHO STATE PLACE OF � t0�EET ADDRESS B, N ME Blair, Nebraska PLAC OF BURIAL OR DISPOSITION HER DISPOSITION Blair Cemetery 2. THIS ATE AN HE REGULATIONS OF THE STATE DEPARTMENT OF HEAL TH PERTAINING TO DEATH CERTIFICATE SE OF DATE SI GN EP 1 .IN AC COR HCE WITH THE LAWS AN A,NS, AU THO IZATION IS HEREBY GIVER TO EG SDIST RICT15 BODY IN THE MANNER INDICATE D- 2. NO THE H OLING OF DEAD H © ^ CAT RE �,I J 18. c. AUTHORIZATION REG TRAR GN,B, v clTr AHD STATE EMET FOR B. STREET ADDRESS DISPOSITION 4A. NAME ERY OR BODY WAS: CREMATORY p�G�. ��7 '�•�7 � DISPOSITION BURIED IB. GATE OF DISPO (TION CEMET ER MANAGER'S SIGNATURE �t„r/L a (SPECIFY) CREM OF BODY 20. TLE I1.0OTHER 19. 1A• A E FFICE REGISTRAR'S SIGNATURE GATE 228. STATE OX 3887 22 A., REGISTRAR USE p1, VS -7 REV. 7-74 DEPARTMENT OF HEALTH SERVICES, HOE NIX.rARIZONA 8503000RO5, P.O. B CTATk rrtc A'®17MIA Jones A. TOWN OR CITY ph apn i v