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PERSONAL & STATISTICAL PARTICULARS |
3. Sex: Male
4. Color or Race: White
DATE OF BIRTH: June 10, 1917
AGE: Still B |
| OCCUPATION:
None |
| BIRTHPLACE:
Cinti, O. |
PARENTS:
Father: Raymond Cole
Birthplace of Father: Cincti, O.
Mother: Agnes Zepf
Birthplace of Mother: Cincti, O.
|
The above is
true to the best of my knownledge:
Informant: Raymond Cole
Address 4232 Williamson Pl. |
Filed: Jun. 11, 1917 - Ewalter Evans, Registrar
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MEDICAL CERTIFICATE OF DEATH |
|
16. DATE OF DEATH: June 10, 1917 |
17. I Hereby Certify, That
I attended deceased from June 10, 1917 to June 10,
1917. I last saw him alive on
___(blank)____, death is said to have occurred on
the date stated above at 8 p.m.
The CAUSE OF DEATH was as follows:
Premature Birth
Stillborn
CONTRIBUTORY over exertion by mother
Signed Mary Roush Kreiger, M. D.
June 10, 1917 -Address: 854 W. 7th. St. |
|
18. LENTH OF RESIDENCE:
N/A |
19. PLACE OF BURIAL OR REMOVAL
St. Joseph's Old.
DATE OF BURIAL: Jun. __ 1917?
Signed Henry F. K___
Date 3/4/1931 Address 1674 Chase, Cinci, O |
20. UNDERTAKER: ___?
Borgeraund?
ADDRESS: Cincti, O. |
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