Place of Death:  County:  Union, Illinois            Usual Residence:  State:  Illinois    County:  Union            City or town:  Dongola
City or Town:  Rural, Rd. Dist. 1-A            Length of Stay:  3 mo. 21 da.            Full Name of Hospital or Institution:  Anna State Hospital
Name of Deceased:  Annie McCommons            Date of Death:  July 16, 1955
Sex:  Female            Color or Race:  White            Married, Single, Widowed, Divorced:  Widowed            Date of Birth:  9-25-1878
Age:  76            Usual Occupation:  Housewife            Birthplace:  Dongola, Ill.    U.S.A.
Father's Name:  George Stoner            Mother's Maiden Name:  Carrie -----
Was Deceased ever in U. S. Armed Forces:  No            Social Security No. none
Informant:  Gretta R. Brasel            Address:  Anna, Ill. (from Hospital Records)

CAUSE OF DEATH:     General Arteriosclerosis            Interval between onset and death:  Unknown
Autopsy:  No
I hereby certify that I attended the deceased from March 25, 1955 to July 16, 1955, that I last saw the deceased alive on July 16, 1955, and that death occurred at 6:30 A. M. from the causes and on the date stated above.
Signature:  Stanislav Zatwardewicz, M. D.            Address and phone no.:  Anna, Ill.   Tel. 1045            Date Signed:  July 16, 1955

DISPOSITION:  Burial:  July 18, 1955            Cemetery:  I. O. O. F., Dongola, Illinois    
Firm Name:  Ford Funeral Home, Dongola, Illinois
Signature:  Elmer J. Ford        License Number:  770

Received for filing on:  July 16, 1955
Signed:  Mary B. Whitney
Address:  Anna, Illinois