| PERSONAL &
STATISTICAL PARTICULARS |
3. Sex: Male
4. Color or Race: White
5. Widower |
| 5a. Spouse
name: Catharine Schubach |
| 6: Date of
Birth: June 13, 1831 |
| 7: Age 79 yrs.
8 mos. 20 ds. |
8. Trade:
Retired
9. Farmer
10. (blank) |
| 12. BIRTHPLACE:
- Germany |
13. FATHERS
NAME: Zepf
14. " Birthplace: Germany |
| 15. MOTHERS
NAME: Unknown |
| 16. "
Birthplace: Germany |
17: Signature
of Informant:
Philip Zepf
Address: 5692 ____ |
18: Burial
place: Spring Grove -
Date: 3__ 1831 |
19. Undertaker:
Chas. F. Miller Sons
19a. Was embalmed: Yes
Embalmers No. ___?_____ |
20. FILED:
____________
Referrer: ___illegible___ |
|
|
MEDICAL CERTIFICATE OF DEATH |
|
21. DATE OF DEATH: 3-3-1931 |
22. I Hereby Certify, That
I attended deceased from Feb. 24, 1931 to March 3,
1931. I last saw him alive on Mar. 3, 1931,
death is said to have occurred on the date stated
above at 9 a.m.
The PRINCIPAL CAUSE OF DEATH and related ___ of
importance in order of onset were as follows:
Influenza - 2-22-31
Broncho - Pneumonia - 2-27-31
CONTRIBUTORY CAUSES of inportance not related to
principal cause.
Chronic endocarditis
What test confirmed diagnosis? __illegible___ |
|
23. N/A |
|
24. Was disease or injury in any
way related to occupation of deceased? NO
Signed Henry F. K___
Date 3/4/1931 Address 1674 Chase, Cinci, O |
|
