IMG 5717 (3)
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Polic Commencins District 18 No. 12065 Sept No. Monday No Table Weekiy Sum Pavable 1C premum No. O200 Dth 38 AUNCNE 23 5 Res. Nos. of other First entry or additionaI J. E Assurances TUNSTALL AND DISTRICT ASSURANCE COLLECTING SOCIETV, STATION CHAMBERS, TUNSTALL. Proposal for Assurance on the Life of Another. (Over age 16). The Proposer is alone respansible for all the following information. 1. Name (in full of Lite Proposed George Lowe 2 AOdreSSIN Full 41 Heatheote St. Kidsgrove 3. Occupation Married or Sinele Married Miner Name (in fulll of Proposer, if temale Mrs Surah Jane state whether MrS. OF MIss Lowe Address in full as Above Relationship to lite proposed. Wife 7. Are you under any obligation to contribute to the (u Tuneral Expenses (a) funeral expenses of the Life proposed to the extent of the sum to be assured or (6) what is the (6) nature of your insurable interest in the Lite PPODOSEA The Lite proposed 82 Month ASCRER Falke was bornat on 26 Juve IBIthSA 1897 Has any near relative of the Life proposed suffered from or died of consumption or any hereditary No AIseasO] ISO. SIVE MII pArICUIANS. PrOPOSAINO. 4 31 Foli0 In Collector's Book. /139 For use by Society Sonus Additions up to 31st Dec., 19 Oate of Entey 19 Sept 192 Date of Exit 24 Aus 1931 Cause of Exit Secession Cause of Oeath Vear of Maturity Actvarial 1896 |
