|
PERSONAL AND
STATISTICAL PARTICULARS |
| 3.
SEX: M |
4.
COLOR OR RACE: W |
5.
Single, Married, Widowed or Divorced: Widowed |
|
5a. If Married,
widowed or divorced.
Husband of Frances |
| 6. DATE OF BIRTH:
Apr. 14, 1855 |
| 7. AGE: 87
years |
8 Months |
5 Days |
|
| 8. Trade,
profession or particular kind of work done:
Freight Handler |
| 9. Industry or
business in which work was done: B. & O. R. R. -
retired |
| 10: Date deceased
last worked at this occupation: (blank) 11.
Total time: (blank) |
| 12. BIRTHPLACE: U.
S. |
PARENTS:
13. FATHER'S NAME: Peter Kneipp |
| 14. FATHER'S
BIRTHPLACE: U. S. |
| 15. MOTHER'S
MAIDEN NAME: Don't know |
| 16. MOTHER'S
BIRTHPLACE: Don't know |
17. Signature of
INFORMANT: Mrs. Cecilia Herman
and (Address) 6325 Desmond St. |
18. BURIAL,
CREMATION OR REMOVAL:
Place: Calvary Date 12-22-1942 |
19. FUNERAL FIRM:
Thomas Funeral Home
19a. BURIED BY: W. Thomas Lic. No. 1740
Address: Cin, O.
EMBALMER: J. _. Graham
Lic. No. 2963A |
20. FILED: Dec.
31, 1942
Jos Dock? Registrar
E. Waller? E__, Registrar |
|
|
MEDICAL
CERTIFICATE OF DEATH: |
| 21.
DATE OF DEATH: Dec. 19, 1942 |
22.
I HEREBY CERTIFY, That I attended deceased from
10-18-37 to 12-19-42, I last saw H__ alive on
12-19-42, death is said to have occurred on the
date stated above at 9AM
The PRINCIPAL CAUSE OF DEATH, and related causes
of importance in order of onset were as follows:
Broncho pneumonia Date of ___: 12/__ ___
Cardio - _____ - _____ Date of __: 1937
CONTRIBUTORY CAUSES of importance not related to
principal cause:
P_llag___ Date of __ 1940 |
23, If death was due to external
causes (violence) fill in also the following:
Accident, suicide, or homicide? (Blank)
|
24. Was
disease or injury in any way related to occupation
of deceased: No.
(Signed)Franklin R. G___
Date: 12/21/1922 Address 5720 Madison Rd. |
|
