|
PERSONAL AND STATISTICAL PARTICULARS |
3. SEX:
Male |
4. COLOR OR RACE:
White |
5. Single, Married,
Widowed or Divorced:
Single |
|
| 6. DATE OF
BIRTH: June 10, 1917 |
| 7. AGE:
Still Born |
| 8.
OCCUPATION: None |
| 9.
BIRTHPLACE: Cinti O |
| 10.
FATHER'S NAME: Raymond Cole |
| 11.
FATHER'S BIRTHPLACE: Cinti O |
| 12.
MOTHER'S MAIDEN NAME: Agnes Zepf |
| 13.
MOTHER'S BIRTHPLACE: Cinti O |
14. THE
ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
INFORMANT: Raymond Cole
Address: 4232 Williamson Pl. |
15. Filed:
Jun. 11, 1917
E. Waller E____, Registrar
|
|
|
MEDICAL CERTIFICATE OF DEATH: |
|
16. DATE OF DEATH: June 10,
1917 |
17. I HEREBY CERTIFY, That
I attended deceased from ________ to
___________, I last saw him alive on
___________, death is said to have
occurred on the date stated above at 8
p.m.
The CAUSE OF DEATH was as follows:
Premature Birth - Still Born
CONTRIBUTORY overexertion of Mother
(Signed) Mary Morish?
Krieger, M. D. |
|
18. (blank) |
19. PLACE OF BURIAL OR
REMOVAL:
St. Joseph's Old
Date of Burial: June 11, 1917
Date: Jan. 2, 1836
Address: 1553 Chase Ave. |
20. UNDERTAKER:
Busse & Borg___ __
ADDRESS: Cinti O |
|
