USA > Michigan > St Joseph County > Three Rivers > Death certificates, city of Three Rivers, St. Joseph county, Michigan > Part 4
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Carriage Paneler
THE ABOVE STATEO PERSONAL PARTICULARS ARC TRUC TO THE BEST OF MY KNOWLEDGE AND BCLICF
(Informant)
Besoin Saxlar
(Address)
Strach Duch
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
(Month)
11
(Day)
(Year)
15
190.2
I HEREBY CERTIFY, That i attended deceased from
12 190.2., to ..... 2,5-2 15 190.2, that | last saw h/.2 .? ) .. allve on. 15 190.2, and that death occurred, on the date stated above, at. .M. The CAUSE OF DEATH was as follows:
Derights .
.. {OURATION)
Contributory.
(DURATION)
(Signed).
11/16
.. 190.2.(Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients or Receot Residents:
Former or
ospal residence
How long et
place of death!
Dayı
Where was disease contracted,
if not at place of death !.
PLACE OF BURIAL OR ACMOVAL
DATE OF OUAIAL
......
2750 17 1907
UNOCATAKCA
Filed
2700 16 1907 Gamer & Burn
Registrar
OD WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD. N. B .- Every Hem nf Information should be carefully supplied. AGE shouff bo ffated EXACTLY. PHYRIUTANGenouIg
The "Special Information" for persons
tho Committee of the American l'ublio licalth Association and JU. 8. STANDARD CERTIFICATE OF DEATH. prepared by
dying away from bnme should be given In every tuainner.
state CAUSE OF DEATH In plain tering, that It may be properly classified.
budy to gecompany It to destination.
A Ileinval l'ornit answer the purpose of a liuriel l'ermit, un.
DUTY OF SEXTON .- Sextonm should not permit an Inter- ment until o properly prepared llorial or Removal l'ermit la Setivered hy the untertaker ar person in charge of the romaine.
ton company, who must attach It to the box containing the
STATE OF MICHIGAN Department of State-Division of Vital Statistics CERTIFICATE OF DEATH
Registered No. 560-
FULL NAME Ralph Edgar Saxloro
. .....
Mopled by the U. S. Consus Omon.]
M. L.
...
PLACE OF DEATH
County of
Township of
or
Village of
or
City of
(NO .......
3ª avro
St .;
.. Ward )
(If death occurred it a Hospital or Institu tion, mise Its NAM !! instead of street at. number !! away from . uqual residedoc, Kiye "Speolai laforma tlon " below ]
FULL NAME
Charles 1. Spears
PERSONAL AND STATISTICAL PARTICULARS
SEX
COLOR
DATE OF BIRTH
(Month)
(Day)
147
(Year)
1865
AGE 11 years,
11 ... months ..........
12days
SINGLE, MARRIED.
WIDOWED, OR DIVORCED
Married
AGE AT MARRIAGE,
NUMBER OF CHILD-
REN
Il married, aga at (first) marriage.
... Fears
(Parent of 3 children, of whom.
2 .. are living
BIRTHPLACE
(State or country)
England
NAME OF
FATHER
Mellan stears
BIRTHPLACE
OF FATHER
(State or country)
England
MAIDEN NAME
OF MOTHER
Francie stay lock
BIRTHPLACE
OF MOTHER
(Stato or country)
Елу
OCCUPATION
Mener
THE ABOVE STATEO PERSONAL PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE ANO BELIEF
(Informant)
La Re Schoonmaker
(Address)
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
(Month)
Nov
(Day) 20
190 .. 7. ...
I HEREBY CERTIFY, That I attended deceased from Nov 23 ,190.7., to Nov 24 1907. that I last saw h/.2/1. alivo on 190.2 ..
and that death occurred, on the date stated above, at
40.
The CAUSE OF DEATH was as follows: Cancer & Lever undiflere. ...
. .. (DURATION)
Contributory ..
Influenza
(GURATION)
(Signed) ..
M. D
Dad2490 .. ). (Address).
SPECIAL ISFORMATION only for Hospitals, Institutions, Transients ur Recent Besidenta:
Former or
asaal residence
How long :1
place of death!
Da
Where wis disease contracted, if not st place of death 1.
PLACE OF BURIAL OR REMOVAL
OATE OF BURIAL
........ ........
.... 1907 ..
UNDERTAKER
Schemmeter Grown
ADORES,
Filed
200 30 1907
James & Bunn
Registrar
atale CAUSE OF DEATH In platu ternie, that It may be properly eineellos.
enppiled, Da- WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD body to accompany it to destination.
-- il.na arn jurat reeutatluns to tho onutrary.
lion cumpany, who must attnch It to the box contaloing tho DUTY OF SEXTUN .- Sextons should not permit an Inter- ment until a properly prepared Huriel or Reinovni Perinit is delivered by the undertaker or person In charge of the remains. A Komoval l'ornit anew om the purpose of n Burial l'ormit, un.
Tho "Hpoolal Information" for poreuse
t'tevarolany arn enrn-
adopted by the U. S. Coomus (Mea.]
the Committee of the American Public Health Association and [U. S. STANDARD CERTIFICATE OF UJEATII, prepared by
ilyløg away from home should be given In overy Instance,
N. IL .- Every lem of Information should be carefully
STATE OF MICHIGAN Department of State-Division of Vital Statistics
CERTIFICATE OF DEATH
Registered No ...
,
(Year)
.
1
PLACE OF DEATH
County cf
St Joseph
Township of
or
Village of
City of ..
3 Divers
119
....
Wood
.St .;
11
.... Ward)
[If deathoccurred ir o Hospital or Institu tlon, give Its NAME Instead of street and number. If away from usual residence. Kive "Special Informa tlon" below.]
PERSONAL AND STATISTICAL PARTICULARS
SEX
Female
DATE OF BIRTH
(Month) Det
(Day)
20
(Year)
1855
AGE
52 years
/
months
-4 days
SINGLE, MARRIED.
WIDOWED, OR DIVORCED
AGE AT MARRIAGE,
NUMBER OF CHILD-
REN
If married, age af (Srst) marriage.
.years
(Parent of 3 children, of whom.
2 are living
BIRTHPLACE
(State or country)
-
mich
NAME OF
FATHER
George Nembra
BIRTHPLACE
OF FATHER
(State or country)
Ja
MAIDEN NAME
OF MOTHER
Catherine Joust
BIRTHPLACE
OF MOTHER
(State or country)
Pa
OCCUPATION
Housewife
THE ABOVE STATED PERSONAL PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEOCE AND BELIEF
(Informant).
James Vr. Oleindon
119 Word St. 3 Dinero
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
(Month)
Nov
(Day)
29
(Year)
190.7
I HEREBY
CERTIFY, That
1
attended deceased from
190.6.,to
For 201 , 1907
that I last saw h.C .. .... alivo on
..
march
700
28
190Z ...
and that death occurred, on the date stated above, at 7:20M
The CAUSE OF DEATH was as follows:
Garanoma of Liver and
Metastatic Garanonía
.
-{DURATION) ..
(DURATION)
DAYS
(Signed).
Brauchen stanze
.. M. L.
190 .... (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients oc Recent Residents:
Former or
osoal residence.
How long et
place of death!
Dats
Where was disease conteacled, if not at place of death ?
PLACE OF BURIAL OR REMOVAL Sunside bene
OATE OF BURIAL
190
UNDERTAKER
Schoonmaker Grout
ADORESS
Filed
Nov 30 1907 James E. Burn
Registrar
N. B .- Every Item of Information should be carefully sopplied. AGE sontd be tuma sxauzunrre
stato CAUSE OF DEATH In plain terms, that it inny be properly olansidod.
DUTY OF SEXTON .- Sextons should not permit an inter- ment until a property prepared Burial or Removal Permit ly deilvered by the undertaker or person in charge of the remains. A Itemoval Permit answers the purpose of n lurial l'ermit, un-
tion company, who must attach it to the box contalolog tho
The "Special Information" for persons
adopted by the U. S. Census Omnce.]
the Committee of the American Public Health Association and IU. S. STANDARD CERTIFICATE OF DEATHI. prepared by
dying away from home should be given In every Inalance.
Iza ilinto aro incal regulations to the contrary.
.....*** * wu -l'hvuciang are caro-
00- WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD. body to accompany it to destination.
STATE OF MICHIGAN Department of State-Division of Vital Statistics CERTIFICATE OF DEATH
Registered No ..
58
FULL NAME
Ella M. Herndon
COLOR
....
Contributory
PLACE OF DEATH
County cf
.
Township of or
Village of
01
(No
123
..... St .:
....
.Ward)
FULL NAME Effin may Lauder
PERSONAL AND STATISTICAL PARTICULARS
SEX
COLOR
DATE OF BIRTH
(Month)
7
(Day) 27
(Year)
1868
AGE 31
.... years,
11
months,
27 days
SINGLE, MARRIED,
WIDOWED, OR DIVORCED
Married
AGE AT MARRIAGE,
NUMBER OF CHILD-
REN
If married, aga at (first) marriage ...
20
.. years
Parent of.
children, of whom.
L. are living
BIRTHPLACE
(State or country)
mich
NAME OF
FATHER
Das. O. Smith
BIRTHPLACE
OF FATHER
(State or country)
MAIDEN NAME
.
OF MOTHER
Eliza Juster
BIRTHPLACE
OF MOTHER
(State or country)
OCCUPATION
THE ABOVE STATED PERSONAL PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF
(informant)
Lacoeur
(Address)
3-Euro
MEDICAL CERTIFICATE OF DEATHI
DATE OF DEATH
(Month)
12
(Day)
(Year)
19
190.
I HEREBY CERTIFY, That ! Die 19 attended deceased from Ocx 16
......
190 .... , to ..
,190.2
that I last saw hs.Y .... .. alive on ....
19 ,190.2. and that death occurred, on the date stated above, at G .COM The CAUSE OF DEATH was as follows: Meningitis
(OURATION). DAYS
Contributory
(OUMATION) DAYE
(Signed)
M. &
Fre 19 1907 (Address).
SPECIAL INFORMATION only for Hospitals, Instilotions, Transients or Receat Besideats:
Farmer or
asnal residence
How long st
-place of death?
Day
Where was disease contrseted, if oot at place of death ?.
PLACE OF BURIAL OR REMOVAL 3 Junio
DATE OF OURIAL
12-22.
.. 190 ..
UNDERTAKER
La Collar
ADDRESS
3-Pers
Filed
DEC 21
. 1907
Samlet Burn
Registrar
adopted by the U. S. Census Office.]
the Committee of the American Public Health Association and [U. S. STANDARD CERTIFICATE OF DEATHI. prepared by
dying away from home should be given In ovory Instance.
stato CAUSE OF DEATH In plain loris, that It may be properly classified.
OG* WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD. body to necompany it to destination.
The "Spoolal Information" for persona
........ nlans aro cara.
N. B .- Every Item of Information should be carefully supplied. ACH Should be Rated MULAVLNA.
" Iloro arn loral regulations to the contrary.
llon company, who must ntinch it to the box containing the DUTY OF SEXTON .- Sextony should not permit nn inter- meot until a properly prepared Burial or Removal Permit 1y delivered by the undertaker or person in charge of the remains. A Removal Permit answers the purpose of a Burial Permit, un.
STATE OF MICHIGAN Department of State-Division of Vital Statistics
CERTIFICATE OF DEATH
Registered No ..
59
(If death occurred 1. n Hospital or Institt. tion, kivo ita NAM: Instead of street an number. If away froc usual residence, kiv. "Special laforma tion " below.]
City of
-
PLACE OF DEATH
County cf ....
Township of .. or
Village of
City of
(No.
606
. St .; .... Ward )
FULL NAME
Lemay a Pourne
[If deathoccurred ! u Hospital or Intilt tion. riTO ILs NAMI fastend of mireet an. oumber. If away frou usual residence. CIT. "Special loforma (loo " below ]
PERSONAL AND STATISTICAL PARTICULARS
SEX
COLOR
DATE OF BIRTH
(Month)
(Day)
29
183%
AGE 73 ..... years. 10 months, 29 days
SINGLE, MARRIED.
WIDOWED, OR DIVORCED
married
AGE AT MARRIAGE. NUMBER OF CHILD- REN
(Il married, age at (Erst) marriage 26
.. fears
(Paret of 2 children, of whom are living
BIRTHPLACE
(State or country)
-
mich
NAME OF
FATHER
food Jouer
BIRTHPLACE OF FATHER (Stato or country)
MAIDEN NAME OF MOTHER Verna stanley
BIRTHPLACE
OF MOTHER
(State or country)
OCCUPATION Retired Farmer
THE ABOVE STATED PERSONAL PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF
(Informant)
nuce
(Address) ..
Ofrequins
MEDICUL, CERTIFICATE OF DEATH
DATE OF
DEATH
(Mooth)
(Day)
(Year)
28
190 ... ..
I HEREBY CERTIFY, That I attended deceased from
190,2 .. , to ore 24, 190.7 that I last saw h !!!... I. alivo on Dec 2.4, 1907 and that death occurred, on the date stated above, at ......... , M The CAUSE OF DEATH was as follows: Sangreur right Road
DURATION)/9/ Day Valvular deserve of lead
Contributory.
(Signed).
Laurence Finale
.. M. L
190 .... (Address).
110 Thais SX
SPECIAL INFORMATION only for Hospitals, lostitolions, Transients or Recent Besideals: Former or ssosl residence
How long al
place of dests!
Darı
Where was disease coolracted, if oot st place of death ?
PLACE OF BURIAL OR REMOVAL
OATE OF MUNIAL
SEc 21
....
190.7
UNDERTAKER
Achammaker Four
ADORESS
3- Euro
Filed
Jazy 1 1908 JumsERmin
Registrar
N. B .- Every Hem of Information should be carefully supplied. AGE"should Tie'statod"PA.AVA .......
40" WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD state CAUSE OF DEATH In pinin farms, that it inny be properly classified. The "Speelal Information" for persons
DUTY OF SEXTON .- Sextons should not permit an inter- ment until a properly prepared lluria! or Removal Permit Is delivered by the undertaker or person in charge of the remains. A Itemoval P'armit answers the purpose of a Burial Permit, un.
body to necompany it to destination.
dying away from home should be given In every Instance.
the Committee of the American Public Health Association and AUDIMIMICATE OF DEATH. adopted by the U. S. Census Office.]
[U. S. STANDARD CERTIFICATE OF DEATH. prepared by
loss there are local regulations in the contrary.
Hon company, who must attach It to the box containing the
STATE OF MICHIGAN Department of State-Division of Vital Statistics
CERTIFICATE OF DEATH
-
Registered No.
600
(Year) ...
Counarientro . DAIS
N. B .- Every Item of Information should be carefully supplied, AGE should be stated EXACTLY. PHYSICIANS should stato CAUSE OF DEATH In plain terms, that It may be properly classified, The "Special Information" for persons dying away from home should be given In every Instance,
[U. S. STANDARD CERTIFICATE OF DEATH, prepared by the Committee of the American Public Health Assoelation and adopted by the U. S. Census Otllee.]
CERTIFICATE OF DEATH.
(. .)
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 fare of certifiento, In space provided nt upper right-hand corner. It should be entered Immediately upon receipt nt your olllee, and the dato of filing In yom office and your signature ny registrar shoukt be entered at the same time on the face of the certifionte in the lower right-hand corner.
Please examine the certificate onrofully before making out the porinit and oall the attention of the undertaker or person In charge of the disposition of the body to any omissions. if any Item cannot be obtained, the space should not be left blank ner a meaningless dash be used, but the word "Unknown" should be plainly written. Be particularly enreful to see that the place of death Is correctly stated. If out of your jurisdiction, do not register It, but see that It Is illed with the registrar where the death occurred. It is not necessary to give the "Speelal Infor- mntlen," except for deaths In Institutions, etc.
Do not fall to mati all certificates of denth filed with you to the Department of State, Lansing, Michigan, on the fourth (4th) dny of the following month, Use the stamped return envelope provided for this purpose, and Ineinde a State- ment Card, properly filled out.
INSTRUCTIONS TO SUBREGISTRARS .- Licensed em balmers, when duly authorized by the Secretary of State to Det as subregistrars, mny issue permits to themselves for deaths lo villages or townships (but not in cities), They must first have the certiflentes completely and legibly filled out to ink, and must personally lite all certificates with the registrars on or before the third day of the following month without fail. The certiflentes sheeld not be numbered by the subregistrars, but by the registrars. who record and transmit as If originally filed with them.
DUTY OF UNDERTAKER. - It Is the duty of the undertaker or other person In charge of the flunt disposition ef n human body to observe the following requirements of the registration Inw: I. Hle must obtain n certificate of death (this blank or any other form ever Issued by the Secretary of State for this pur- pose will be satisfactory), and have It properly Illled out with all of the personni and statistical particulars required by law. This part of the certificate should preferably be signed by a rela- tive or friend of the decedent, or by some competent person nequainted with the facts. It may be signed by the undertaker or by the physician If desired.
2. The certificate contulning the above persennl partleninrs must now be presented to the attending physician for the medt- eat cortifiente of cause of death. If the physician Is absent, so that the medlent certificate cannot be promptly obtained, the Incomplete certiflente may be then presented to the registrar with a statement of thnt Inet. The registrar may thereupon, In bis diseretlon, Issue a conditional permit, provided the medical certificato be completed at the earliest possible moment. Ilut registrars will exerelse especial eantien in granting such condi- tional permits to Insure that the death did not result from any Infectious disease, requiring sanitary preenutions, or from unlaw- ful or suspicious moans. If any douht exists, or In the ense of a denth witheut medical attendance. the registrar will refer the certifieate to the llenitb Omleer (if n physician) or Coroner for Investigation and statement of cause of death. If the Ilealth Officer Is not a physleton, the registrar may insert the cause of denth In denths occurring without medleal attendance from competent testimony over his offlelal signature.
3. The undertaker or person In charge of the disposition of the body must next present the complete certiflente of denth, containing the medical certificate of canse of death, to the Itegistrnr of the township, village or elty where the death occurred; nud obtain his permit for the burial or re- moval of the bedy before any disposition is made of it.
4. The undertaker should dellver the Registrar's Hurinl Permit to the Sexton when the Interment Is made, or, If the bedy Is removed by rail or boat, the Registrar's Removal Per- mit must be delivered by bim to the ogent of the transporta-
llon company, who must attach it to the box containing the body to necompany It to destination.
DUTY OF SEXTON .- Sextons should not permit on later- ment antil a properly prepared Hluriol or Removal Permit is delivered by the undertaker or person In charge of the remains. A ltemoval Permit answers the purpose of a Burlal P'ermit, un- less there are local regulations to the contrary,
SUGGESTIONS TO PHYSICIANS,-Physicians are cara- estly requested to facilitate the execution of the law, and espeel- Ally. as far as It may be in their power, to ald undertakers to their auty of promptly obtaining a statement of cause of death. Illank certifleates will be supplled to all physicians In the State upon request, and may be obtained nt any time from the local registrars. Physicians should have n supply of blanks on hand, and In the event of donth, kindly leave the meillea] cortificate of enuse of denth with the faintly of decedent, or have it ready for the undertaker so that he will not be de- Inyed In obtaining tho periett. Compliance with this request, which will remove one of the principal difficulties of prompt registration, will be greatly appreciated.
"The statement of enuse of death la very important for many reasons. Please be prealso and dettutte in making out the medi- ent eertlifeate. If the denth occurred from enncor or tubar- enlonla, state what part of the body was affected. If from Neptleemin, give the cause of the septicemia, especially for fe- males ef childbearing ngc. Never repert a death from "heart fuifare;" it is universally diseredited as a statement of cause of death. If such a death was due to netenl heart disease, stato that fact; or if the "heart fullere" occurred In the course of diphtheria or other disense, give the name of the disease that enused the "heart failure."
EXTRACT FROM THE REGISTRATION LAW. Compiled Laws, 1897, §§ 4614-4620, as amended by Publle Act No. 20 of 1901.
SECTION 1. The People of the State of Michigan enact, That the body of no person whose dentb occurs in the State shall be la- terred, deposited in n vault or tomb or otherwise disposed of, or removed from the township, village or city in which the denth occurred, until n permit for burlat or remeval shall have been properly Issued by the clerk of the towaship, village or city in which the denth occurs, who shall be the registrar of deaths.
SEC. 2. Whenever any person shall die, the undertaker, house- holder, relative, frlend, manager of Institution, sexten or other person superintending the burial of sald deceased person, shall cause a certificate of death to be filled out with all the personal and family particulars required in section three of this act, and attested by the signature of a relative or some competent per- son acquainted with the Incts. The physician who attended the deceased person during his Inst illness shall illl out the medi- eal certificate of cause of death. Upon the
presentation of a certifiente of death properly filled out and signed, the registrar shall Isane a permit for the burlut or removal of the body and shall Immediately record the death In the regis- ter of denthy, numbering all certilleates consecutively In the order In which they are received, beginning with No. I for the Ilest death that occurs in each year. In deaths frem dangerous communlenble diseases, burtol or removal permits shall be granted by the registrar only in necordance with the rules of the local beard of health and the State Board of Health relating thereto. The sexton or other person having charge of the Inter- ment or fiant disposition of the body shall retain the burial per- mit when presented to him by the undertaker: Provided, That when a hody Is shipped the removal permit shall be presented by the undertaker or other person shipping the same to the agent of the transportation company, and shall be attnebed by him, with the transit permit, to the box containing the body, to ne. company the same to destinatien, and no transit permit shall be Issued or received by any transportation company for the ship- ment of a body unless accompanied by the registrar's removal permit.
Sic. 6. An official Inlling or refusing to perform his duty under this net, er noy undertaker violating any of Its provisions, shall. upon conviction thereef, be deemed guilty of a misdemeanor. and shall be punished by a fine of not less than five dollars and not exceeding one hundred dollars, or be Imprisoned In the . county jail not exceeding thirty days, or suffer both fine and Im- prisonment at the diseretion of the court. Local registrars shall see that the provisions of this Det are enforced la their jurls- dictions
Copies of the law and blank certificates of death will be supplied by the Local Registrar or by the Secretary of State.
.
HECKMAN BINDERY, INC. Bound-To-Please"
MAR 01
N. MANCHESTER, INDIANA 46962
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