Mary Newell ThornburghORIGINAL—White KANSAS DEPARTMENT OF HEALTH & ENVIRONMENT
FILE—Yellow Bureau of Registration & Health Statistics
Topeka, Kansas 66620
OUT-OF-STATE TRANSIT PERMIT
Full name of decedent MARY NEWELL THORNBURGH Age 83 Sex FE
Date of death 7-19-1988 Place of death WICHITA SEDGWTCK KANSAS(State)
(City or Township) (County) (
BLAIR CEMETERY BLAIR NEBRASKA
'Point of final destination (city) (State)
(Cemetery, Crematory ° or Other Point of Destination)
PERMIT
-
A certificate of death having been filed as required by the laws of the State of Kansas, permission is hereby given to:
MICHAEL R AST 1998 JULY 22 1981
(Funeral Director's Name) (License No.) (Date Issued) r
j
WULF MORTUARY BOX 27 GARDEN PLAIN KANSAS 67050
(Name and Address of Firm)
'to remove the above Kansas for final disposition.*
ove ide tified body from the State o
Issued by R FUNERAL DIRECTOR GARDEN PLAIN KS. 670
Nivnature of Funeral Director or Local Registrar) (Title) (Address)
Embalmer's name MICHAEL R. AST License No. 3036
The above transit permit is required for the removal of any dead body from the State of Kansas for interment,
storage or cremation and is to accompany the body to the point of final disposition. (This form is not to be used for
disinterments.)
0,
ORIGINAL—White KANSAS DEPARTMENT OF HEALTH & ENVIRONMENT
FILE—Yellow Bureau of Registration & Health Statistics
Topeka, Kansas 66620
OUT-OF-STATE TRANSIT PERMIT
`Full name of decedent MARY NEWELL THORNBURGH Age83 Sex FE.
Date of death 7-19-1988 Place of death WICHITA SEDGWICK KANSAS
(City or Township) (County) (State)
BLAIR CEMETERY BI -AIR NEBRASKA
Point of final destination c;t (state)
(Cemetery, Crematory ° or Other Point of Destination) ( y)
I
�A certificate of death having been filed as required by the laws of the State of Kansas, permission is hereby given to:
MICHAEL R. AST 1998 .JULY 22 1981
(Funeral Director's Name)
License No.) (Date Issued)
W[TLF MORTUARY BOX 27 GARDEN PLAIN KANSAS 67050
(Name and Address of firm)
,to remove the above identified body from the State of Kansas for final disposition.'
° E, FUNERAL DIRECTOR GARDEN PLAIN KS. 67050
Issued by ISivnature of Funeral Director or Local Registrar) (Title) (Address)
„Embalmer's name MICHAEL R. AST License No.
3036
'The above transit permit is required for the removal of any dead body from the State of Kansas for interment,
storage or cremation and is to accompany the body to the point of final disposition. (This form is not to be used for
disinterments.)
TYPE
OR PRINT
IN
PERMANENT
INK'
FOR
INSTRUCTIONS
SEE
HANDBOOK
a @
IF DEATH
OCCURREDIN
INSTITUTION,
SEE HANDBOOK
REGARDING
COMPLETION OF
RESIDENCE ITEMS.
DISPOSITION
KANSAS STATE DEPARTMENT OF HEALTH AND ENVIRONMENT
VITAL STATISTICS
LOCAL FILE NUMBER CERTIFICATE OF DEATH STATE FILE NUMBER
DECEDENT—NAME FIRST MIDDLE LAST
SE%DATE
OF DEATH (Month, Day, Year)
MARY NEWELL THORNBURGH
FEMALE
7-19-1988
1.
2 ,.
AGE—Last Blnhdey
UNDER l YEAR
UNDER , DAY
DATE OF BIRTH Day, Yr.)
RACE—(fig, WtMe, Black, American Indian, otc.) ORIGIN
OR DESCENT (e.g., Italian, Mez'ran,
(Yrs.) 83
I .
4 MOS. ; DAYS
HOURS : MINS.
jr,(Mo.,
11-17-1904
`SV ty WHITE (specify)
68
German, Puerto Rican,
English, Cuban, etc.)
COUNTY OF DEATH
CITY, TOWN OR LOCATION OF DEATH
HOSPITAL OR OTHER INSTITUTION—Nana (tf rot in either, give street and number)
IF HOSP. OR INST. indicate ODA,
SE ICK
,. WICHITA
, 2220 CEDER CREST
7d OWN IOM`
STATE OF BIRTH (11 iwl in U.S.A.,
CITIZEN OF WHAT COUNTRY
MARRIED. NEVER MARRIED,
SURVIVING SPOUSE (If vote, give maiden name)
WAS DECEDENT EVER IN U.S.
name country)
IOWA
91 U.S.A.
WIDOWED, DIVORCED (Speaty)
WIDOWED
11 NONE
ARMED FORCES?
(Specify Yes a No)NO
SOCIAL SECURITY NUMBER
USUAL OCCUPATION (Give kind of work done during most of
KIND OF BUSINESS OR INDUSTRY
13. 505-86-8098
GROCERY 111eSTOR'If`OWNER
„ GROCERY
RESIDENCE—STATE
COUNTY
CITY, TOWN OR LOCATION
STREET AND NUMBER
INSIDE CITY LIMITS
, KANSAS
SEDGWICK
WICHITA
,2220 CEDAR CREST
or
`°° 0 "°)
I
FATHER—NAME First Middle LastM
OTHER—MAIDEN NAME First Middle Last
JACOB - ABBOT HILLMAN
HARRIET LOUISE THOMAS
NFORMANT—NAME (Type or Print)
MAILING ADDRESS STREET OR R.F.D. NO. CITY OR TOWN STATE ZIP
1. ALMA ANSKIVER
,. 2220 CEDAR CREST WICHITA KS. 67212
BURIAL, CREMATION, REMOVAL, OTHER (Specify)
CEMETERY OR CREMATORY—NAME
LOCATION CIN OT TOWN STATE
198 —BURIAL
.BIAIR CEMETERY
BLAIR, NEBRASKA
FUNERAL SER /CE LIC NSEE LIC NSE NO
'�°"°'Ofe'►
NAME OF EMBALMER Si LICENSE NO
NAME & ADDRESS OF FIRM T.TI TF L'' T..f RTTi ATD [7 _
Pl llJtiKS
1998
MICHAEL R. AST 3036
^ DEN ET TN.
Z 21a. To the best of my kn0Med9e, death occurred at the time, dale and place and due to the
22a On Ma basis of ezamnation ands investigation, in my opinion death occurred at the time,
< cause(s) slated. 0"Q
aU
date and place and due to the cause(s) staled.
�ifo
N (Sioneture and T I
ISionelure and Tda1�
DATE SIGNED (Mo.. Day, Yr)
HOUR OF DEATH
Q DATE SIGNED (Mo, Day. Vr)
HOUR OF DEATH
lb.
152 M
ZW
M
A<O¢O 2
22 M
o w NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type a P -1)S
PRONOUNCED DEAD IMO. Day, Yr.)
PRONOUNCED DEAD (Hour)
U
<
22d. ON
220 AT M
NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, MEDICAL EXAMINER OR CORONER( (Type or P-1)
CONDITIONS gEGISTRAR
IF ANY ►
WHICH GAVE
RISE TO 25. IMMEDIATE CAUSE
IMMEDIATE
CAUSE PART
(ENTER ONLY ONE CAUSE PER LINE FOR (a). (b), AND (c).)
DATE RECEIVED BY REGISTRAR (Mo, Day, Yr.)
Waiver between onset and death
4q I