|
PERSONAL AND STATISTICAL PARTICULARS |
3. SEX:
Female |
4. COLOR OR RACE:
White |
5. Single, Married,
Widowed or Divorced:
Widowed |
|
5a. If
married, widowed or divorced
WIFE of Joseph Hack |
| 6. DATE OF
BIRTH: April 1st 1853 |
| 7. AGE: 84
yrs. 7 mos. 22 days |
OCCUPATION:
8. Housewife
9. (blank)
10. (blank) 11. (blank) |
| 12.
BIRTHPLACE: Cincinnati, Ohio |
| 13.
FATHER'S NAME: Peter Kneipp |
| 14.
FATHER'S BIRTHPLACE: Germany |
| 15.
MOTHER'S MAIDEN NAME: Caroline King |
| 16.
MOTHER'S BIRTHPLACE: Cincinnati, Ohio |
17. The
signature of INFORMANT: Mrs. Rodgers
Address: 6224 Madison Rd. |
| 18.
BURIAL, CREMATION OR REMOVAL: St.
St. Mary's Cem. Date:
11-26, 1937 |
19.
FUNERAL FIRM: Dunn & Lashbrook
19a. BURIED BY: Jas. T. Lashbrook
Lic. No. 1052
Address: 6111? Madison Rd.
19b. EMBALMER: Jas. T. Lashbrook
Lic. No. 3130A |
20. FILED:
Nov. 24, 1937 E. Waller ____
Registrar
E. Waller E____, Registrar |
|
|
MEDICAL CERTIFICATE OF DEATH: |
|
21 DATE OF DEATH: Nov. 23,
1937 |
22. I HEREBY CERTIFY, That
I attended deceased from May 6, 1937 to
Nov. 23, 1937, I last saw her alive on
Nov. 23, 1937, death is said to have
occurred on the date stated above at __ m.
The PRINCIPAL CAUSE OF DEATH and related
causes of importance in order of onset
were as follows:
Aortic Insufficiency - Date of
onset ?
Chronic Myocardial disease
CONTRIBUTORY CAUSES of importance not
related to principal cause:
Chronic ____________ Nephritis |
23. (blank)
|
24. Was disease or injury
in any way related to occupation of
deceased? No.
If so, specify_(blank)_
(Signed: M. C. La______, M.D.
Date: 11/24, 1937 Address: 4015
Allston St., Cincinnati, O.
Address: 1553 Chase Ave. |
|
