ARIZONA STATE DEPARTMENT OF HEALTH

BUREAU OF VITAL STATISTICS

CERTIFICATE OF DEATH

STATE FILE NO. 1091

REGISTRAR'S NO. 690



PLACE OF DEATH AND AL RESIDENCE

PLACE OF DEATH: (a) County Maricopa, (b) Length of Stay: In this town 44 Years; in Arizona 44 Years. (c)City or Town: Phoenix, In City Limits (d) Full name of Hospital or Institution 3613 N 5th Ave, Apt D-2 USUAL RESIDENCE (a) State Arizona (b) County: Maricopa (c) City or Town Phoenix (d)Street Address 3613 N 5th Ave, Apt D-2 (e) Is residence on a farm No

PERSON DATA



Name of Deceased Ruth D'Allemand Sex: FEMALE Color or Race: W



(a)Married, never married, widowed, or divorced Widowed (b) Name of husband or wife: None Date of Birth 04-26-1888 Age 76 (a) Usual Occupation Housewife (b)Kind of Business or Industry Homemaking Birthplace New York Citizen of What Country USA


Was Deceased Ever in US armed Forces No Social Security No. UNK

(a) Father Name: Addis Albro (b) Father's Birthplace: New York

(a) Mother Maiden Name: Unknown Scribner(b) Mother's Birthplace: New York

(a) Informant's Signature: Charles F.(Records of AL Moore & Sons,) (b) Address Phoenix AZ

Date of Death 05 09, 1964

CAUSE OF DEATH

Disease or Condition Directly Leading to Death: (a) Acute Myocardial Infarction due to (b) coronary arteriosclerosis due to (c) blank Other Significant Conditions Age Interval Between onset and death May 29, 1964

OPERATIONS, AUTOPSY

(a) Date of Operation blank (b) Major finding of Operation blank

Autopsy Yes

I hereby certified that I attended the deceased, from May 1963 and to May 29,1964, That I last saw the deceased alive on May 28,1964, and that death occurred at 3:00pm, from causes on the date stated above.

(a) Signature AJ Klown MD (b) Address 926 E McDowell Rd. Phoenix (c) Date Signed 06/01/64

DEATH DUE TO EXTERNAL VIOLENCE

Blank

CORNER'S CERTIFICATION

Blank

FUNERAL DIRECTOR AND REGISTRAR

(a) Burial, Cremation or Removal BURIAL (b) Date 06-2-64 (c) Place: Greenwood Cemetery (d) Location, Phoenix AZ

(a) Date Rec. by local Reg 06-2-64 (b) Registrar's Signature Helen E Macnab

(a) Funeral Director's Signature A. L. MOORE & Sons. (b) Address Phoenix AZ

(a) Embalmer's Signature Robert Tracy (b) Embalmer's Cert. No 282