|
PERSONAL AND STATISTICAL PARTICULARS |
3. SEX:
Male |
4. COLOR OR RACE:
White |
5. Single, Married,
Widowed or Divorced:
Widower |
|
5a. If
married, widowed or divorced
HUSBAND of Ida Grable |
| 6. DATE OF
BIRTH: May 23, 1858 |
| 7. AGE: 77
yrs. 7 mos. 8 days |
OCCUPATION:
8. None
9. (blank)
10. (blank) 11. (blank) |
| 12.
BIRTHPLACE: Germany |
| 13.
FATHER'S NAME: Stephen Zepf |
| 14.
FATHER'S BIRTHPLACE: Germany |
| 15.
MOTHER'S MAIDEN NAME: Barbara |
| 16.
MOTHER'S BIRTHPLACE: Germany |
17. The
signature of INFORMANT: Mrs. Lewis
Thome?
Address: 4215 Williamson Pl. |
| 18.
BURIAL, CREMATION OR REMOVAL: St.
Joseph Old Date: Jan. 3, 1936 |
19.
UNDERTAKER: Chas. A. Miller Sons
(Address) Cinti
19a. Was body embalmed Yes
Embalmer's No. 3636A |
20. FILED:
Jan. 2, 1936
E. Waller E____, Registrar |
|
|
MEDICAL CERTIFICATE OF DEATH: |
|
21 DATE OF DEATH: Dec. 31,
1935 |
22. I HEREBY CERTIFY, That
I attended deceased from March, 1933 to
Dec. 31, 1935, I last saw him alive on
Dec. 28, 1935, death is said to have
occurred on the date stated above at 3
a.m.
The PRINCIPAL CAUSE OF DEATH and related
causes of importance in order of onset
were as follows:
Apoplexy - Date of onset: Dec. 31, 1935
CONTRIBUTORY CAUSES of importance not
related to principal cause:
Arteriosclerosis - Date of Onset: 1933 |
23. (blank)
|
24. (Signed) J. S. Tarrant,
M. D.
Date: Jan. 2, 1836
Address: 1553 Chase Ave. |
|
