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�`�C�O �� <br /> 1��. �C��,]L��T���J� ��EC ��.� �J <br /> 21917—The Auguatine Co., County Supplies, Grand Island, Nebr. <br /> CERTIFICATE OF DEATH � <br /> 1. F ULL NAME Qua ndt, John Augu s t <br /> 2. PLACE OF DEATH: (A) �ounty Orang� <br /> (B) City or Town Oranpe <br /> If outside city or town limits, write rural <br /> (C) Name of hospital or institution <br /> St.Jos� h Hos �. <br /> f not in osp a or ins i u on, give s r�e num er or location <br /> (D) Length of Stay: (specify whether yeaxs,months or da.ys <br /> In Hospital or institutian I da� <br /> In this community 19 yrs. in California 19 y�ars. <br /> (E) If forei�n Born, ho�� long in the U. S.A. -- -----Years. <br /> 3, U�UAL RESIDENCE OF DECEASED, <br /> (A) State California <br /> (B) County 0�'ange <br /> ( (3� City or Town -Orange <br /> If outsid� city or town limits, Write Rural <br /> (D) �treet No. 1017 E.Palmyra St. <br /> 3. (E) IF VETEftAN,NANE OF p�IAR 3. �F� SB�3�, SECURITY N0. <br /> no. 550-03-93�3 <br /> 4. Sex 5. COLOR OR RACE 6. (A) Singl�,Ntarried,Widow�d or Diac�rced <br /> Male White Married <br />' 6. (B) NAME OF HUSBAND OR WIFE 6. {C) Ag� oP Husband o� Wife if Alive <br />�.. C lara Quandt --------Years. <br /> k� 7. BIRTHDATE OF DECEASED May 19, 1�76 <br /> Month Day Y�ar <br /> �. AGE 6� yrs. 6 Mos. 2�- days. If Less than one day old ---Hrs. ---Min. <br /> 9. BIRTHPLACE Caledonia, Wis. <br /> 10. USUAL OCCUPATION Retired Farmer <br /> j 11. INDUSTRY OR BUSINESS Self <br />'i FATHER -12.r�fAME August Quandt <br />� -1,3.HIRTHPLACE Germany <br />� MOTHER ' -11�.MAIDEN NAME '-Henriett� I���mp <br /> I 15.BIRTHPLACE Germany <br /> r 16. (A) INFORMANT R.A. Quandt <br />'i (B) ADDRESS 1017 E.Palmyra St. <br /> 17. (A) Entombment (B) DATE 12/16��4 <br /> . Burial, Cr. ema:ti.on or remov�l. <br /> (C) PLACE Fa.irhaven Mausoleum <br /> 1�. (A) EMBALM:FR�� LICENSE <br /> SIGNA'�Lii�P R�x Shannon N0. 2209 <br /> (B) FUNEftAL DIRECTOR Shannon Funeral Home <br /> Address Orange, California <br /> F3y Rex Shannon <br /> 19. (A) Dec. 15, 1944 (b) Edw.Lee Russell,M. D. <br /> - � <br /> Date Filed Registra�' s 8ignature <br /> 20. DATE OF DEATH: Month December Day 13 <br /> YEAR 19�-� HOURS 1 MINUTES j0 p.m. <br /> 21. MEDICAL CERTIFICATE <br /> I hereby certify that I attended the deceased from z2/� 19�3 to 12/13 19�F�- � <br /> Th�t I last saw him alive on 12�13 19��, and that death occured on �he date <br /> an�t hour statPd above. <br /> IA+I�IEDIATE CAUSE OF DEATH DURATION <br /> Pulmonary ed�ma 1 wk : <br /> Due to Endocarditis, chronic , 3": yr'�• <br /> Due to Arterios�lerosis 3 yrs. <br /> Other Conctitions --------------- <br /> ' (Includ� pre�nancy tvithin tnree months of death) <br /> Ma.j or Findings; <br /> Of oper�tions Dat� of <br /> ------------------------Operation --------- <br /> Of Autopsy --- --�-=-----PHYBICIAN <br /> Underline the cause to which deat�i should be charged s�atisti- <br /> cally. <br /> 22. CORON�R' S CERTIFICATE. <br /> I hereby certify th�.t I held an -- ---- ----------------------------- on the remains <br /> autopsy, inr�uest or investig�,tion <br /> o�' t:�e deceased and find from such �ction th�t deceased came to h-- death on the d�te <br /> an� n.ot�r stated above. <br /> 23. IF DEAT�-i ?�IAS DUE TO EXTERNAL CAtJSES, FILL IN TF�E FOLLOWING: <br /> (A:�: ACCIDENT, SUICIDE OR HOMICIDE------------- <br /> (S DATE 0�' I1�JLTRY <br /> ( C WHERF DID INJr:�RY OC^UR ---�ity---rr��r-�Gounty-�---------State. -- <br /> (D) DID I'��JURY OCCUR IN OR ABOUT HOI��E, ON FARM, IN INDUSTIRAL PLACE, OR IN PUBLIC PLACE <br /> _ _ ----------- WHILE AT WORK -----------=--- <br /> �pecify T�rpe or Pl�.ce <br /> 24. CORONER'S or <br /> PHYS��IAN' S S�GNATjJRE Verne W. Carlson, M.D. <br /> pecify �+hich) <br /> ADDRESS Oran�e, Calif. Date 12/1�-/�-4 <br /> State of California CERTIFICATE OF DEATH U. S.DEPT,OF COMPViERCE <br /> DEPARTMFNT OF PUBLIC HEALTH BUREAU OF THE CE"�SUB <br /> State of California � s�. I hereby certify the foregoing to be a full tr.Ae and correct <br /> County of Orange, � co�y of tne Death certif icate of Quandt, John August, as the <br /> same a���,ears on record in my office. <br /> Witness my nand and official seal this 3rd d8y of March, 19�+5• <br /> Edw.Lee Ruase�.l,M.D. <br /> (SEAL) Health Officer, Orange County, <br /> By Betty A2.cFerran <br /> Filed ior record this 16th c3�.y o� Maren, �9t�5� a� 1: 30 o ' cloc�uPy�r_egistrar���� ��� <br /> � �egister of Deeda <br />