Missouri State Board of Health
Bureau of Vital Statistics
Certificate of Death

File No. 20332
Registered No. 10

1.  PLACE OF DEATH
	County: Putnam
	Township: Medicine
	City: Lucerne Mo.
2.  FULL NAME: Amelia Cooley
    Length of residence in city or town where death occurred: 12 months
3.  SEX: female
4.  COLOR OR RACE: white
5.  SINGLE, MARRIED, WIDOWED OR DIVORCED: married
5a. SPOUSE: Greenberry Cooley
6.  DATE OF BIRTH: [blank]
7.  AGE: 84 years, 2 months, 8 days
8.  OCCUPATION: House Wife
9.  BIRTHPLACE: Taylorville, Ohio
10. NAME OF FATHER: Joseph Pettit
11. BIRTHPLACE OF FATHER: Pennsylvania
12. MAIDEN NAME OF MOTHER: Amelia [sic] Pettit
13. BIRTHPLACE OF MOTHER: Ohio
14. INFORMANT: Joseph W. Cooley, Lucerne, Mo.
15. FILED: 6/20, 1930, Fannie Young, Registrar
16. DATE OF DEATH: 6-19th 1930
17. I HEREBY CERTIFY, That I attended deceased from 6-2d, 1930
    and that I last saw her alive on 6-18th, 1930, and that death
    occurred, on the date stated above, at 6 p. m.
    THE CAUSE OF DEATH was as follows: artero sclerosis
    CONTRIBUTORY: senility
18. (signed) F D Rice, Lucerne, Mo.
19. PLACE OF BURIAL, CREMATION OR REMOVAL: Busby Cemetery
    DATE OF BURIAL: 6/21 1930
20. UNDERTAKER: J Lee Hawk, Lucerne