Shelby  County  Health  Forms

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 State Board of Health

State Board of Health Form


Patient's name           Edward Lee
Single, married, widowed or divorced (write word)           Widowed
Name of Husband or wife
Birthplace (state or county)           Tipton County, Indiana 
Name of father           Thomas Lee
Birthplace of father (state or country)           Indiana
Maiden name of mother           Anna Phillips
Birthplace of mother (state or country)           Kentucky
Occupation           Common Labor
Date           Oct 7, 1921                                                         Signed by Virgil R. Phillips


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