State File No.:  15429
 1.  PLACE OF DEATH:
     a.  County:  TARRANT
     b.  City or Town:  SANSOM PARK
     c.  Length of Stay in 1b:  1 YEAR
     d.  Name of Hospital or Institution:  FOUR SEASONS NURSING CENTER
                                           2129 SKYLINE DRIVE
     e.  Is Place of Death Inside City Limits?  YES
 2.  USUAL RESIDENCE:
     a.  State:  TEXAS
     b.  County:  TARRANT
     c.  City or Town:  WESTWORTH VILLAGE
     d.  Street Address:  997 ROARING SPRINGS ROAD
     e.  Is Residence Inside City Limits?  YES
     f.  Is Residence On a Farm?  NO
 3.  NAME OF DECEASED:  PEARL NEVA BALLARD
 4.  DATE OF DEATH:  2-3-1973
 5.  SEX:  FEMALE
 6.  COLOR OR RACE:  WHITE
 7.  WIDOWED
 8.  DATE OF BIRTH:  1-6-1883
 9.  AGE:  90
10a. USUAL OCCUPATION:  HOMEMAKER
10b. KIND OF BUSINESS OR INDUSTRY:  HOME
11.  BIRTHPLACE:  SPRINGFIELD, MISSOURI
12.  CITIZEN OF WHAT COUNTRY?  USA
13.  FATHER'S NAME:  ADDISON PANCAKE
14.  MOTHER'S MAIDEN NAME:  SARAH LIPPMAN
15.  WAS DECEASED EVER IN U.S. ARMED FORCES?  NO
16.  SOCIAL SECURITY NO.:  [blank]
17.  INFORMANT:  Edwin W. Ballard
23a. BURIAL, CREMATION, REMOVAL:  REMOVAL-BURIAL
23b. DATE:  2-6-1973
23c. NAME OF CEMETERY OR CREMATORY:  MT. HOPE CEMETERY
23d. LOCATION:  BELLEVILLE, ILLINOIS
24.  FUNERAL DIRECTOR'S SIGNATURE:  HARVESON AND COLE
                                    Guy Thompson  3280
25a. REGISTRAR'S FILE NO.:  26
25b. DATE REC'D BY LOCAL REG.:  FEB 9 1973
26.  REGISTRAR'S SIGNATURE:  Ruth B. Braddock