STATE FILE NO.:  69-037956
 1.  PLACE OF DEATH:  a. COUNTY:  Polk
                      b. CITY, TOWN, OR LOCATION:  Winter Haven
                      c. IS PLACE OF DEATH INSIDE CITY LIMITS?:  Yes
                      d. NAME OF HOSPITAL OR INSTITUTION:  D.O.A. Winter Haven Hosp.
 2.  USUAL RESIDENCE:  a. STATE:  Florida
                       b. COUNTY:  Polk
                       c. CITY, TOWN OR LOCATION:  Winter Haven
                       d. STREET ADDRESS:  319 Avenue B., South-East
                       e. IS RESIDENCE INSIDE CITY LIMITS?:  Yes
 3.  NAME OF DECEASED:  Charles   Pancake
 4.  DATE OF DEATH:  June 13th, 1969
 5.  SEX:  Male
 6.  COLOR OR RACE:  White
 7.  MARRIED
 8.  DATE OF BIRTH:  Dec. 26, 1882
 9.  AGE IN YEARS:  86
10a. USUAL OCCUPATION:  Locomotive Engineer
10b. KIND OF BUSINESS OR INDUSTRY:  Railroad
11.  BIRTHPLACE:  Lawrence co., Ohio
12.  CITIZEN OF WHAT COUNTRY?:  U.S.A.
13.  FATHER'S NAME:  not available
14.  MOTHER'S MAIDEN NAME:  Mary Jane==-----
16.  SOCIAL SECURITY NO.:  709-10-9539
17.  INFORMANT'S SIGNATURE AND ADDRESS:  Mrs. Lillian V. Pancake, 319 Ave. B.,S.E., Winter Haven, Fla.
[Cause of death is omitted]
23a. BURIAL, CREMATION, REMOVAL:  Burial
23b. DATE:  June 15, 1969
23c. NAME OF CEMETERY OR CREMATORY:  Lakeside Memorial Pk.
23d. LOCATION:  Winter Haven, Florida
24.  FUNERAL DIRECTOR'S SIGNATURE AND ADDRESS:  E. Gerald Jackson  Ott-Laughlin
                                                                   Winter Haven, Fla.
25.  DATE RECD. BY LOCAL REG.:  June 13, 1969