This text was obtained via automated optical character recognition.
It has not been edited and may therefore contain several errors.
u?k.i T~~-~-r-.r~?*y-.n. - M yar &-^^gsr^Sy- striotiii zsss '? ? ??%?^^-!iC?rroll Curtl. -3r."~r' I gaggiirS^.^grf^.^ [*.<*}?* v??or?*? ????*?** ??;???^?,1 o*t.-rM>DtCAL CCRTIFICATION vTTSv?^? ?~.?~r----.-? ?--------:?&? ? n*;,* m^^MSSL^s? tc>Wy_iX94> ' 'Iwmw_,^T '.?t'a. m. ~ 3i&tU - M.. ? MrMrt^r Wat l inimi tfta |?WMI< -??. -ft. /mriO ?_,* mat fUM saw hJ_^ljllv. ?.! /jr. TV-0 j; 1?_| , 7*V^?F*'C^? Kaoa ? <a) SJn*!*, wllwii, aiirW, - >a p.* '-ITh 1 f "Tiewrawllaxrl -.??v _ I ? <?) A?a ?l bMteM irv)?Ma' IT 3toia?Ila BvQUaaasi. -iiJ'v- jw' :r> ioril Vtk^-igQO1^^ (Month) ???r.-(DM>-.r?? ? (TW) fcAU: YMrr ^'rr MontiM Oaym ?:?2'^ ? If Iom than mw My-V tr^: V ? ? * ???1 .<? ft'-1 R?tlgaU-* ' ' j^(CJ*y.town, or Monty) (St*M or foraicr* ooantry) 2dL??i _____Zr?J; Ihar'lat jllli.._ n^V&Sj^CHy,. towtk or oovmtjr) . - (8tB|a or torolffn eouatry) IfcTla, -.-La.?** City, town, or county) ; p?7U.. u4s>. * (City. tow*, or wuaty) (St?t* or foraJ*n oooatry) OlIlM mhIKImi ---.? ._?*> :? (laefada pnffMMT wlthla t b Jr?.Roialla ,Gurti?.' .. \h) >T7pii|^ri?<wT<f? ,nrnrr~'l ^ (Month) (Doy)<.Y*or) airing -1'Cq, tfoatfc mcwt?? on th? Mta antf **vr iUtt< tWw. IniMMiti mmo of 4aatH_ ?***?* i ?th? of doath) MAJOR PtNOtNOS: ,Of e#erstioee _________ isQt ?ut?Hy -.^?-JJ. OURATIOM .*? PHY?IC1AN Uit*ertfn<!?^v( tho MUM M - whM M?th ? ft ? u 1* : If Math waa riu< U ?xtamal utim, fill in tft? (?) AoaiMnt, Mitcltf*. ?r h?m)?id? (tpMlfy)____________________ - ???" '? ? (i) Data *f >MMrra*?M.________________!__________________ . ' : - .,'r. wtt <?) WlMn tfW Injury oeour?_____________________________________i---- - ,,... (Cltrortown) (County) (Stmt*) " (4) DM injury omup In or about feoma, on farm, in Irvtfuotrfal
Zimmerman 003a