USA > Michigan > St Joseph County > Three Rivers > Death certificates, city of Three Rivers, St. Joseph county, Michigan > Part 3
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Pa
MAIDEN NAME
OF MOTHER
Elsie Garnison
BIRTHPLACE
OF MOTHER
(State or country)
OCCUPATION
Arx Farmer
THE ABOVE STATEO PERSONAL PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF
(Informant):
Isaac Schoonmaker
(Address)
"Phry .. ..-- ier ..
MEDICAL CERTIFICATE OF DEATH
DATE OF
DEATH
(Month)
(Day)
11
(Year) 190.7.
I HEREBY CERTIFY, That I attended deceased from
1
190 ... ,to.
J .!... ,190.,
that I last saw h.
LDA .. alive on
and that death occurred, on the date stated above, at ..
The CAUSE OF DEATH was as follows: Brights Geral
.. (DURATION)
Contributory ...
asthma Cancer
Paralyon
(QURATION).
3
(Signed)
arThuy W Sadmin
M. L.
9/12
190,Z.(Address)
SPECIAL INFORMATION aoly for Hospitals, Institutions, Transients or Recent Besideots:
Former or
usoal residence
How long al
place of death?
Days
Where mas disease contracted, if not at place of death ?.
PLACE OF BURIAL OR REMOVAL
Thise Kivers
DATE OF BURIAL
Selex 14
190 .. 7.
UNDERTAKER
Schoon maler Jamil
ADDRESS
Three Rivers,
Filed
1907. JAMES E BUNN
Registrar
..
DUTY OF SEXTON .- Sextons should not permit an Inter-
himyWo) Konomjany It to destination.
PLACE OF DEATH
STATE OF MICHIGAN Department of State-Division of Vital Statistics
CERTIFICATE OF DEATH
117
Registered No ...... .....
{If deathoccurred lo a Hospital or Institu- tion, give Ita NAME Instead of street and number. If away from usual residence, give "Special Informa- tlos " below.]
....
COLOR
... )
less there are loral regulations to the contrary. ment until a properly prepared Burlai or Removal Perinit Is delivered by the undertaker or person In charge of the remains. A Removal Permit answers the purpose of n Burial Perunit, un- SUGGESTIONS TO PHYSICIANS .- Physicians are cara. ently requested to facilitate the execution of the law, and espcel- ally, as far na it inny bo in their power, to nid undertakeis in their duty of promptly oftalulng a statement of onuse of death. Hiank certifientes will be supplied to all physicians in the Sinte upon request, and inv be obtained nt nny timo from the lonl
-
Sept 10 ,190,Z.,
-
INSTRUCTIONS TO REGISTRAR .- The registered num- ber may be Inserted In space above, If desired, for your own con- venience. It Is recommended, however, that it bo entered auly
CERTIFICATE OF DEATH.
PLACE OF DEATH
County cf ..
Of Joseph
Township of
Village of. or
City of --. Throc . Rivers,.
FULL NAME
Lulu
Harrington
STATE OF MICHIGAN Department of State-Division of Vital Statistics CERTIFICATE OF DEATH
(No.
110
Grant and
-St .;
............ Ward)
[If deathoccurred in a Hospital or Institu- tion, give Its NAME Instead of street and number. If away from usual residence, give "Special Informa- tion " below.]
PERSONAL AND STATISTICAL PARTICULARS
COLOR
SEX
$
DATE OF
BIRTH
(Month) 1
(Das)
5
...
(Year)
1870
....
AGE
...... years,
8
.months,.
18 days
SINGLE, MARRIED,
WIDOWED, OR DIVORCED
AGE AT MARRIAGE.
NUMBER OF CHILD-
REN
If married, age at En; marriage ..
18 years
(Parent of children, of whomare living
BIRTHPLACE
(State or country)
mich
NAME OF
FATHER
BIRTHPLACE
OF FATHER
(state or country)
Ga
MAIDEN NAME
OF MOTHER
Arma Borey
BIRTHPLACE
OF MOTHER
(State or country)
OCCUPATION
THE ABOVE STATED PERSONAL PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF
(Informant)
L.a. Follow
(Address)
Three Rivers,
MEDICAL CERTIFICATE OF DEATHI
DATE OF DEATH
(Month)
4.
(Day)
23
190.2.
I HEREBY CERTIFY,
That 1
attended deceased
from
aug
/03
190.7., to
Rafet 23
........ , 190 .. 7,
Nept 23
5WM
that I last saw her
alive on ..
.... , 190.2 ...
and that death occurred, on the date stated above, at.
The CAUSE OF DEATH was as follows: Gulmonary abscess
-(DURATION). DAYE
Contributory
(DURATION)
DAYS
(Signed).
I Estamos
.M. D.
26/ 231907 (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients or Recent Residents:
Former or
osnal residence
How long at
place of death?
Day
Where was disease contracted, if not at place of death ?..
PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Dept. 2V-190
UNDERTAKER
L.a. Collar
ADDRESS
„truc Rivers,
Filed
Dept 23 1907 JAMESE BUNN
Registrar
Registered No
11-8
adopted by the U.
( ...
wow .S. Census Office.]
....... )
lesy there are local regulations to the contrary. DUTY OF SEXTON .- Sextons should not permit an Inter- ment until a properly prepared Hurlal or Removal Permit is delivered by the undertaker or person In charge of the remains. A Removal Permit answers the purpose of a Burlal Peruilt, un- SUGGESTIONS TO PHYSICIANS .- Physicians are caro- estly requested to facilitate the execution of the law, and especi- ally, as far as It inny bo In their power, to afd undertakers in their duty of promptly obtaining a statement of cause of death. Blanke certificates will be supplied to all physicians In the State upon request, and may be obtained at any thine from the loonl registrara. P'hyalelans should have n supply ut binnks on
hamil, and In the event ar dont1.
body tu accompany It to destination.
1
(Year)
CERTIFICATE OF DEATH.
PLACE OF DEATH
County cf
Township of
or
Village of
of
City of .. fibree . Rivers;
FULL NAME.
Laurence
STATE OF MICHIGAN Department of State-Division of Vital Statistics
CERTIFICATE OF DEATH
Registered No ...... .
[if death occurred in A Hospital or Institu. tion, give ita NAMI. Inetend of street and oumber. Ifaway from unuat residence, give "Special loforma- tion " below. ]
PERSONAL AND STATISTICAL PARTICULARS
SEX
COLOR
11
DATE OF
BIRTH
(Month) Guy
(Day)
(Year)
1907
AGE
- .............. years.
/
months,.
3
days
BINGLE, MARRIED.
WIDOWED, OR DIVORCED
AGE AT MARRIAGE, NUMBER OF CHILD- REN
( If married, age at (first) marriage .. - .. Jears Parent of ....... children, of whom ....... are living
BIRTHPLACE
(State or country)
NAME OF
FATHER
Cafer a wheeler
BIRTHPLACE
OF FATHER
(State or country)
Mich
MAIDEN NAME
OF MOTHER
Samantha frederick
BIRTHPLACE OF MOTHER (State or country) Nich
OCCUPATION Carpenter
THE ABOVE STATEO PERSONAL PARTICULARS ARE TAVE TO THE BEST OF MY KNOWLEOCE ANO BELIEF
(Informant)
Raphael
(Address) -Rivers;
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
(Month)
(Das)
25
.......
190 ..
I HEREBY CERTIFY, That 1 attended deceased from
20 190 to 12/2/23 .,190 .. . that I last saw he .?.! L. alive on. 190 .... and that death occurred, on the date stated above, at M. The CAUSE OF DEATH. was as follows: Malnicheline 1
Contributory
(Signed) M. C.
190 .... (Address).
SPECIAL INFORMATION only for Hospitals, fastitations, Transients or Recent Residents: Former or asaal residence
How long at
place of desth!
Dayı
Where was disesse contracted, if not at place of death !
PLACE OF BURIAL OR REMOVAL Pinside
OATE OF BURIAL
Sept 26 1907
UNOÇATAKEA L.a Collier
a Donca.
Filed Sepet 25 1907 JAMESE RINN Registrar
....... )
adopted by the U. S. Census Omfoc.]
( ......
INSTILECTIONS TO REGISTRAR. The registered num- lør may be Inserted in apaco ative, If ilealred, for your own coni. venirnca. It Is recommended. however, that It he entered only
. ... ......... ......
less there are toent regulations to the contrary. HUITY OF SEATON .- Sextons should not permit an Inter- ment until a properly prepared Burial or Removal Perinit is delivered by the undertaker or person in charge of the remains. A Removat Permile answers the purpose of a Burini Perunit, un. SUGGESTIONS TO PHYSICIANS. Physicians are carn. extly requested in faellitate the expention of the fuw, and cipeel. allv. ny far ne It inny ho In their power, to nid umlerinkris In Their duty of promptly obtaining a statement of euuse of death. Hank certiflentes will bo supplied to att physicians in the State upon request, and may be obtained at any time from the fungi registrars, I'hvaleinos should have a supply nr bolovle. ....
(DURATION)
(DURATION)
(Year)
....
1/07
.... Ward)
.. .
..
PLACE OF DEATH
County cf
Le Juph
Township of
or
Village of
or
City of
21Rivers
(No.
118
main
.. St .;
Ward)
[If deathoccurred in a Hospital or Institu- tlou. give its NAME instead of street and number. If away from usual residence, give "Special Informa- tloo " below.]
FULL NAME
Robert St. Cann
PERSONAL AND STATISTICAL PARTICULARS
SEX
male
COLOR
White
DATE OF BIRTH
(Month)
12
(Das)
29
(Year)
1 898
AGE
8
.- years,
9
.months,
1
days
BINGLE, MARRIED.
WIDOWED, OR DIVORCED
Single
AGE AT MARRIAGE.
NUMBER OF CHILD-
REN
Il married, age at (frily marriage ..
Parent of ......_ children, of whom .....__ are living
.... years
BIRTHPLACE
(State or country)
Oh.4.
NAME OF
FATHER
J. L Cam
BIRTHPLACE
OF FATHER
(State or country)
Sty.
MAIOEN NAME
OF MOTHER
Lulu Stayes
BIRTHPLACE
OF MOTHER
(State or country)
OCCUPATION
Student
THE ABOVE STATED PERSONAL PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF
(Informant)
La Collver
(Address)
2Rivers
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
(Month)
9
(Day)
30
190 ..
I HEREBY CERTIFY, That I
attended deceased from
Sep 8
190.3 .. , to
lef 30
,190.) .. ,
that I last saw h.Yxx.x. alive on ...
Sep 20
190.7 .. ,
and that death occurred, on the date stated above, at.
1:30
A.M
The CAUSE OF DEATH was as follows:
Tuberculous Anmingitis
... (OURATION)
(OURATION)
(Signed)
w. & clark
M. D
Sub 30 190.7. (Address).
SPECIAL INFORMATION only for Hospitals, Institutions, Transients or Receot Residenta:
Former or
nsnal residence
How long at
place of death!
D
Where was disease contracted, if not at place of death ?.
PLACE OF BURIAL OR REMOVAL
Louisville Ky
DATE OF BURIAL
Oct 2
190
UNDERTAKER
L. G. Coller
ADDRESS
3 Rivers
Filed
lefe. 20 1907
Janvez C. Bum
Registrar
.
CERTIFICATE OF DEATH.
adopted by the U. S. Census Offlec.]
( ......
INSTRUCTIONS TO REGISTRAR .- The registered num- ber may be Inserted In space above. If desired, for your own con- venlenee. It is recommended, however, that It be entered only en faro of certificate, In xpago provided nt upper right-linnet
body to Adoumpnny It to destination.
less there are local regulations to the cootrury. DUTY OF SEXTON .- Sextons should not permit an inter- ment until a properly prepared Burial or Removal Perinit is delivered by the undertaker or person in charge of the remains. A Removal Permit answers the purpose of a Burial Permit, un- SUGGESTIONS TO PHYSICIANS .- Physicians are earn- estly requested to faeliftate the execution of the law, and espcel- nlly, ns far ns it mny be In their power, to nid undertakers la thelr duty of promptly obtaining a statement of enuse of death. Blank certiflentes will be supplied to all physielany in the Sinte upon request, and may be obinlned at any thine from the loon!
registrara. I'hyalcinna should have a supply of blanks on band, ond in the event of donth, kindly leave the milleni
euroer
.)
STATE OF MICHIGAN Department of State-Division of Vital Statistics
CERTIFICATE OF DEATH
Registered No.
50
(Year)
Contributory
3 Rivers mich
CERTIFICATE OF DEATH.
PLACE OF DEATH
County cf -
St Joseph
Township of
or
Village of ..
or
City of
ThreePierre
(No.
.. St .;
2
Ward)
FULL NAME
Walter & Van Gelder
STATE OF MICHIGAN Department of State-Division of Vital Statistics CERTIFICATE OF DEATH
Registored No.
51
[If deathoccurred in a Hospital or Institu- tloo, give its NAME instead of street Bod number. If away from usual residence, give "Special Informa- tlon " below.]
PERSONAL AND STATISTICAL PARTICULARS
SEX
Mais
COLOR
While
DATE OF
BIRTH
(Month)
9
(Day) 17
(Year)
1.866
AGE
.years,
.. months,
17
days
BINGLE, MARRIED.
WIDOWED, OR DIVORCED
married
AGE AT MARRIAGE,
NUMBER OF CHILD-
REN
If married, aga at (first) marriage 22 years
Parent of 6 children, of whom.
6 are living
BIRTHPLACE
(State or country)
And
NAME OF
FATHER
Deur laub elder
BIRTHPLACE
OF FATHER
(State or country)
MAIDEN NAME
OF MOTHER
Dusan Whitman
BIRTHPLACE
OF MOTHER
(State or country)
Ohio
OCCUPATION
Paul rader
-
THE ABOVE STATEO PERSONAL PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF
(Informant)
L-aCollar
(Address) ...
3Burro
MEDICAL CERTIFICATE OF DEATHI
DATE OF DEATH
(Month)
Och
(Day)
(Year)
190.2.
3
I HEREBY CERTIFY, That I
attended deceased from
Oct
3
190.Z.,
that I last saw h //21.
·
and that death occurred, on the date stated above, at
10:30PM
.M.
The CAUSE OF DEATH was as follows:
Valvular Heart
Chronic nephritis
.(DURATION)
Contributory ...
Dropsuy
- (DURATION)
DAYS
(Signed).
arthurdi, Sadmore
M. C.
1014
190,Z.(Address).
SPECIAL INFORMATION only for Hospitals, Institutions, Transicols or Receot Besideote:
Former or
usual residence.
How long at
place of death?
Days
Where was disease contracled,
if not al place of death ?
PLACE OF BURIAL OR REMOVAL
White Pigeon
DATE OF BURIAL
1017
7
1904
UNDERTAKER
La Collever
ADDRESS
Filed
Och 5 1907
Jarrive & Bueno
Registrar
office, and the date of Mlling In vinne .. nl. .
INSTRUCTIONS TO REGISTRAR .- The registered num- ber may be Inserted In space above. If desired, for your own con- venience. It Is recommended, however, that it be entered only on face of certificato, in space provided at opper sicht-hand corner. It should be entered Inmediately upon reneipt at your
ally, na far na it may bo in their power. to nid undertakeis In their duty of promptly obtaining a statement of cause of dentl. Ilank oertiflestes will bo supplled to nil physicians in the Suite upon request, and may be obtained at any time from the Inonl registrare, Thyaicinua should have a supply of binatin un hand, and In the event of death, liadly touse the medical
estly requested to Inellitate the execution of the law, and espeel-
ment until a properly prepared Burial or Removal Permit Is delivered by the undertaker or person In charge of the remains. A Removal Permit answers the purpose of a Burial Perunit, un.
less there are Joenl regulations to the contrary.
SUGGESTIONS TO PHYSICIANS .- Physicians are carn-
Of sexTON .- Sextons should not permit an Inter-
... )
1907 ... , to
Sett 25
- alive on ..
,190.7.,
700
adopted by the U. S. Census Oflec.] (U. S. STANDARD CERTIFICATE OF DEATHI. prepared by the Committee of the American Public Health Association ond CERTIFICATE OF DEATH.
00- WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD. body to necompany it to destination.
1. Tht Wroomst Taformation" for persons
PLACE OF DEATH
County cf
Township of
Village of ..
or
City of
Ihres Quin
(No .- Main
.. St .; ............
.Ward)
FULL NAME.
Ellen Doute
PERSONAL AND STATISTICAL PARTICULARS
SEX Female
COLOR
DATE OF
BIRTH
(Month)
(Day)
11
(Year)
1821
AGE 86
....... years,
Z .... months, ........
24
.days
SINGLE, MARRIED.
WIDOWED, OR DIVORCED
Nidound
AGE AT MARRIAGE.
NUMBER OF CHILD-
REN
If married, age st (first) marriage.
Parent of of children, of whom are living
.. years
BIRTHPLACE
(State or country)
. Ga
NAME OF
FATHER
Greggs Marsh
BIRTHPLACE
OF FATHER
(State or country
MAIDEN NAME
OF MOTHER
base
BIRTHPLACE
OF MOTHER
(State or country)
Gas
OCCUPATION House keeper
THE ABOVE STATEO PERSONAL PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF
(Informant)
MEG.Ixvaló
(Address)
3 Puvino
MEDICAL CERTIFICATE OF DEATH
DATE OF
DEATH
(Month)
Oct
(Day)
5
(Year)
190.2 ..
attended deceased dejar 10
,190Z .. ,to
...
,190.
Och 5
that I last saw h ....!.... alive on
Oct
5
,190.
and that death occurred, on the dato stated above, at
110.
The CAUSE OF DEATH was as follows:
Hia Colitica
Contributory ...
Debility stage
·
-- (DURATION)
(Signed)
Launuce Denowas
M
Oct 7 1907 (Address).
SPECIAL ESFORMATION only for Hospitals, Institutions, Transients or Recent Residents:
Former or
asaal residence
How long st
place of death?
Where was disease contracted, if not at place of death ?
PLACE OF BURIAL OR REMOVAL
Finnside
OATE OF BURIAL
Oct 8
190
UNDERTAKER
Schoonmaker Grout
ADORESS
Filed
Och 8
-1907 Damist. Bunun
..
Registrar
( ..
....
venience. It la recompena
her may be Inserted In mundo niner. If itomtrent
INSTRUCTIONS TO REGISTRAR .- The regleferent num.
llon company, who must attach It to the box containing the DUTY OF SEXTON .- Sextons should not permit an inter- less there are local regulations to the contrary. ment until a properly prepared Burini or Removal Permit Is delivered by the undertaker or person in charge of the remoins. A Removal Permit answers the purpose of a Burial Permit, un- SUGGESTIONS TO PHYSICIANS .- Physiofans are corn- estly requested to Inciilinto the execution of the Inw. nad empeel.
their duty of promptly obtaining n.
olly. as far as It may be in their power, to put mult
..... )
STATE OF MICHIGAN Department of State-Division of Vital Statistics CERTIFICATE OF DEATH
Registered No. 5-
[If deathoccurr a Hospital or Ins tion, give Its N. instead of street number. Ifaway usual residence. "Special Info tloo " below.]
I HEREBY CERTIFY, That
(OURATION).
10
adopted by the U. S. Census Office.] IU. S. STANDARD CERTIFICATE OF DEATH, prepared by the Committee of the Amerienn Puldle Health Association aud CERTIFICATE OF DEATH.
ad" WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD. WXTITe gele terme, that it may be properly alneallied .
PLACE OF DEATH
County cf
Township of or
Village of. or
City of Ihre Quinn
505
(No .............. ..
Olensaut
....
FULL NAME Maria Late
PERSONAL AND STATISTICAL PARTICULARS
SEX Female
COLOR
.
DATE OF BIRTH
(Month) Och
(Day) 23
(Year)
1007
AGE
...
.... .years.
months m days
SINGLE, MARRIED.
WIDOWED, OR DIVORCED
AGE AT MARRIAGE, NUMBER OF CHILD- REN
( If married, age at (first) marriage .. years Parent of ... children, of whom ...... are living
BIRTHPLACE
(State or country)
Ofrer Queme
NAME OF '
FATHER
2. 0 Lake
BIRTHPLACE OF FATHER (State or country)
Mich
MAIDEN NAME CF MOTHER Ida Gelvi
BIRTHPLACE OF MOTHER (State or country) Mich
OCCUPATION nome
THE ABOVE STATCO PERSONAL PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF
(Informant)
L&Lake
(Address
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
(Sfoath)
(Day)
(Year)
26
190.7 ...
I HEREBY CERTIFY, That I 23
,1907 ... , to.
Set 26
190.7.
that I last saw h ........ alive on.
Dar 26
,1907 .. ,
and that death occurred, on the date stated above, at
100
......
. M.
The CAUSE OF DEATH was as follows: ) Probably Valuation start
{DURATION).
Contributory.
(Signed)
.M. B.
10/2/ 1907 (Address).
SPECIAL INFORMATION only for Hospita's, lastitations, Transients or Recent Residente:
Former or asnal residence
How Jeaz al
pise of death !
Dary
Where was disease contracted, if not at place of death !.
PLACE OF OURIAL OR REMOVAL
Finnaide Cemetery
DATE OF BURIAL
Och 27 1907
UNOCATAKEA -70
Filed
Oct 27 1907 Jamie 6. Bunal
..
Registrar
..
tion company, who must ntinch It to the box containing the
body to arrompuy it to destination.
DUTY OF SEXTON. - Sexting should not permit an Inter. ment untli a properly meparod Burini or Ilemorni /'print in delivered by the underinher or person In charge of the reinatne. A Removal Pormit anewer tho porponen of a flurin! !.......... ....
lom there are lonal regulail .... ... .... ............
for
dying awny framn hnmn alonid ho given In overy Instance,
-
STATE OF MICHIGAN Department of State Division of Vital Statistics CERTIFICATE OF DEATH
Registered No.2 ... 3.
.St .. ..........
Ward)
[If death occurred i a ffospital or Instit! tion. give It. NAM! Instead of street en number. If away frot usual residence. giv "Special Toform: tion " below.]
attended deceased from
(DURATION)
:
alupted by the U. S. Census Omco.] IU. 8. STANDARD CERTIFICATE OF DEATH, prepared by the Committee of the American Public Health Association and CERTIFICATE OF DEATH.
dring away from home should be given In every Instance.
Da- WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD. VWWWWFWF MR.ATIT IN HETA Ofme, that It inay be properly olassided. The "Spoolal Information" for persona
PLACE OF DEATH
County cf ..
Township of יזה
Village of
or
City of .
(No ...
FULL NAME Farine
Varenman
PERSONAL AND ST.ITISTICAL PARTICULARS
SEX
COLOR
DATE OF BIRTH
(Month)
(Das)
(Year)
AGE 81
.. years, 1 months .....
5 days
SINGLE. MARRIED.
WIDOWED, OR DIVORCED
lideri
AGE AT MARRIAGE,
NUMBER OF CHILD-
REN
. Fears
( If married, age at (Grst) marriage.
(Pareal of 8 children, of whom.
6 are living
BIRTHPLACE
(State or country)
NAME OF
FATHER
Tel Pauck
BIRTHPLACE
OF FATHER
(State or country)
Cai
MAIDEN NAME
OF MOTHER
Mary Long
BIRTHPLACE
OF MOTHER
(State or country)
Va
OCCUPATION Invalid for years
THE ABOVE STATED PERSONAL PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF
(Informant)
(Address).
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
(Month)
11
(Day)
(Year)
.......
I HEREBY CERTIFY, That t attended deceased from
1700 10
,190.Z.,to
. ...
nov 12
,1902,
that | last saw h ........ alive on
3:0000
190 ... ,
and that death occurred, on the date stated above, at
The CAUSE OF DEATH was as follows:
Paralessio followa
Full met
Contributory .
vil yours
(OURATIO*)
(Signed)
2:1 /.3190.7. (Address).
SPECIAL INFORMATION only for Hospitals, lastitations, Transients or Recent Residents:
Former at
asmal residence
How leaz at
place of death!
Darı
Where was disease contracted, if not at place of death 1.
PLACE OF BURIAL OR REMOVAL
OATC OF BURIAL
Nov 14
190 ..
UNDERTAKER
L.a. Collau
ADDRESS
3Quins
Filed
Nov 13 907 Janus E Forum
Registrar
Joen there are lunel repuinttane in the onntraer.
DUTY OF SEXTON .- Sexlons should not permit an Inter- ment until a properly prepared Hurlal or Removal l'erinlt la delivered by the undertaker or person in charge of the remains. A Removal l'ermit answer the purpose of a iturial l'ormit, un
body to accompany It to destination.
flon company, who must attach It to the box containing tho
STATE OF MICHIGAN Department of State-Division of Vital Statistics
CERTIFICATE OF DEATH
Registered No. 11
5€
St .;
2
Ward)
(If death occurred In a Hospital or lostiiu. Uon, rire lu NAMI Instead of street mod pumber if away from usual realdenor. KITE "Special Ioforma- Lion " below.]
12
190.7.
1C
11
.M. L.
Od- WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD. body to accompany it to destination.
llon compnoy, who must attach it to the box containing the
The "Special Information" for persons
KORT EXACTLY. PHYSICIANS KHÔNG
PLACE OF DEATH
County cf
Township of
or
Village of ..
City of
(No.
Miring
St .:
.....
."m Ward)
FULL NAME
Ginge Nicht an .V
.
..
[If death oocurred Ir. a Hospital or lostitu- too, RITO ItA NAME lostead of street and number Ifaway from usuni residence, KITC "Special Informa- tlon " below. ]
PERSON.IL AND STATISTICAL PARTICUL.IRS
SEX mais
COLOR
DATE OF BIRTH
(Month)
(Day)
(Year)
14
1834
AGE €8
years,
8
months,.
29 days
SINGLE, MARRIED.
WIDOWED, OR DIVORCED
Hidorad
AGE AT MARRIAGE,
NUMBER OF CHILD-
REN
( It married, age at (first) marriage ............ years
Parent of 6 children, of whom are living
-
BIRTHPLACE
(State or country)
Mary &auch
NAME OF
FATHER
Влет Яваши
BIRTHPLACE
OF FATHER
(State or country)
Gennaio
MAIDEN NAME
OF MOTHER
Rachel Gough
BIRTHPLACE OF MOTHER (State or country) Germany
OCCUPATION
.
Muller
THE ABOVE STATED PERSONAL PARTICULARS ARE TRUC TO THE BEST OF MY KNOWLEDGE AND BELIEF
(Informant)
David draw
(Address)
Gelina, Ched
MEDIC.IL CERTIFICATE OF DEATH
DATE OF DEATH
(Mooth)
(Day)
13
(Year) 190.2. . -
..
attended deceased from Det 19
190.7 .. , to ..... 13 190,2 ,
that i last saw h /2.2.1 .. alive on .,190.,2., and that death occurred, on the date stated above, at 7:150; The CAUSE OF DEATH was as follows:
- (DURATION)
26
Contributory.
(DURATION ).
(Signed).
Frank 5 mayer
M. L.
202131907 (Address).
How long et place of desth! SPECIAL INFORMATION only for Hospitals, Institutions, Transients or Recent Besideoto: Former or canal residence
Where was disesse contracted, if oot at place of death ?
PLACE OF BURIAL OR REMOVAL
Celina, Chey
DATE OF BURIAL
200 15
190 ...
UNDERTAKER
Schoonmaker Grout
ADDRESS
30
Filed
700 13 1907
Jamis EBuuu
Registrar
(U. S. STANDARD CERTIFICATE OF DEATHJ. prepared by
dylog away from home should be given In every Instanon.
state CAUSE OF DEATH Jo plata termin, that it may be properly classified.
adopted by tbo U. S. Census Oftec.]
tho Committee of the American Public Health Association and
A Hmmwvaf I'neinit Anserm ihn purjuseg of n ilittal P'ranit, un.
delivered by the undertaker or person In charge of the remains.
DUTY OF SEXTON .- Sextons should not permit an Inter. meat until n properly preparod Ihiring or Ieinovnl Perunit in
: 1
STATE OF MICHIGAN Department of State-Division of Vital Statistics
CERTIFICATE OF DEATH
......
Registered No.
55
I HEREBY
CERTIFY, That I
PLACE OF DEATH
County cf
Township of
or
Village of
or
City of
(No. 11776 Guver
.St .;
Ward)
[{{ death occurred in A Hospital or Institu- Lion, KIYe IL4 NAME Instead of street and Dumber. If away from usual residence, cire "Special loforma- tloo " below ]
PERSONAL AND STATISTICAL PARTICULARS
SEX
mais
COLOR
DATE OF
BIRTH
(Month)
Jeby
(Day) 26
(Year)
1.86 9
AGE
38
.years,
8.
... months ........
... days
SINGLE. MARRIED.
WIDOWED, OR DIVORCED
Married
AGE AT MARRIAGE.
NUMBER OF CHILD-
REN
( If married, age at (frsl) marring !.
20 Years
(Parest of at children, of whom 2 are living
BIRTHPLACE
(Stato or country)
Mich
NAME OF
FATHER
Frank M. Daylow
BIRTHPLACE
OF FATHER
(State or country)
The
MAIDEN NAME
OF MOTHER
Emrin Bowman
BIRTHPLACE
OF MOTHER
(State or country)
Qa
OCCUPATION
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