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County
of:
Township
or Road District or Village:
Primary Dist
No.:
Full
Name: Lula BENSON
Residence
No.:
Sex:
Female
Color
or Race: Colored
Single,
Married, Widowed or Divorced:
If
married, widowed or divorced
Husband
of (or) Wife of:
Date
of Birth: November 25, 1914
Age: Years
months
days
Occupation
of Deceased: Child
Birthplace:
NAME
OF FATHER: Frank BENSON
BIRTHPLACE
OF FATHER: Kentucky
MAIDEN
NAME OF MOTHER: Mary WOOLFOLK
BIRTHPLACE
OF MOTHER: Illinois
INFORMANT:
B.C. CROSSLAND
ADDRESS:
FILED:
DATE
OF DEATH: June 29, 1923
CAUSE
OF DEATH: Acute Appendicitis
SIGNED:
PLACE
OF BURIAL: Methodist Cemetery
DATE
OF BURIAL:
UNDERTAKER:
W.A. Gaunt
ADDRESS: Grand
Chain, Illinois
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