|
PERSONAL AND STATISTICAL PARTICULARS |
3. SEX:
Male |
4. COLOR OR RACE:
White |
5. Single, Married,
Widowed or Divorced:
Widowed |
|
5a. If
Married, Widowed or Divorced:
Husband of Josephina Yeager |
| 6. DATE OF
BIRTH: 4/16/1866 |
| 7. AGE:
75 yrs. 8 mos. 26 ds. |
8.
OCCUPATION: Farmer
9. Industry or business in which work was
done: Retired
10. Date deceased last worked at this
occupation: ___
11. (blank) |
| 12.
BIRTHPLACE: Campbell, Ky - U. S. A. |
| 13.
FATHER'S NAME: Nicholas Yerger |
| 14.
FATHER'S BIRTHPLACE: Germany |
| 15.
MOTHER'S MAIDEN NAME: Louisa Kneipp |
| 16.
MOTHER'S BIRTHPLACE: Germany |
17. The
Signature of INFORMANT:
Miss Marie C. Th____ling
and (Address) St. Francis Hospital |
18.
BURIAL, CREMATION OR REMOVAL:
Fayetteville, O Date:
Jan. 15, 1942 |
19.
FUMERAL FIRM: C. B. Eichelburger
19a. BURIED BY Same
Lic. No. 39
Address: Blanchester, O
19b. EMBALMER: J. _ Keefe Lic. No.
4066A |
| 20. FILED:
Jan. 1_, 1942 |
|
|
MEDICAL CERTIFICATE OF DEATH: |
|
21. DATE OF DEATH: 1/12/42 |
22. I HEREBY CERTIFY, That
I attended deceased from 10/15/41 to
1/12/42, I last saw him alive on
1/11/42, death is said to have
occurred on the date stated above at 1:40
p.m.
The CAUSE OF DEATH was as follows:
Arterioscherotic ___________ failure
Was there an autopsy:
No
|
23. (blank)
|
24. Was disease or injury
in any way related in occupation of
deceased?_____
If so, specify_______
(Signed) A. F. R_____, M.D.
79_1 ________ |
|
