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<br /> NIISCELI�ANEOUS RECORD V
<br /> 29OSH-TN811U6U5TINECO.GRIINDISLAND,NEBR. � . � . . , . '
<br /> S t at e of Okl anoma )
<br /> )ss Subscribed and �sworn to be�'ore me this 20 day of May, Zg�9.
<br /> Count;,r of Okl�,��omu. )
<br /> (SEAL) Beth Smith
<br /> Notary Public
<br /> Conmission expires Jan. 16, 19�0 ,
<br /> Filed f or record the 2 day of June �9�9, at 9:00 o� clock A.M.
<br /> 4��!��
<br /> � REG7STER �JF DEEDS
<br /> o-o-o-�-o-a-o-a-o-o-a-o-e-o-c-o-o-o-o-a-o-o-o-o-o-o-o-o-o-o-o-o-a-o-o-c-o-o-o-o-a-o-a--o
<br /> C�TIFICATE OF DEATH ORIGINAL
<br /> #2�7 State F3.1e No.
<br /> 1.. PL�CE OF DEAT'ri: Registration Il ��5 STATE OF ILLINOIS
<br /> County of Cook, Illinois Dist-. No. 310�- DEPARTMETdT OF PU�LIC HEALTH
<br /> City, Township, Chicago Primary D�.vision of Vita1. Statisties and
<br /> Dist. No. �10�- � Records Registered No. : 12302
<br /> Stree't and Number 1773 W. Con�ress S�. Presbyterian Hospital
<br /> LENGTH OF STAY: In Hos�ital or Tnsti�ution - Yrs. - Mos. 21. Days. : In Community where
<br /> �.eath occurred Yrs. �Ios. 21 Days.
<br /> 2. PLACE OF State Illinois, County Cook Towsnhip, Road Dist.
<br /> RESIDETdCE City or V3.11.ags Park Ridge Street and No. 2�4 Vine St.
<br /> 3. (a) FULL :1A��E REV. FRED Z�d. BENJAMIN
<br /> 3. (b) If Ve�eran, name �aar No
<br /> �• (c) Soc3.al Security No. None
<br /> . Sex Male
<br /> 6. Co1or or raae �nlhite
<br /> l�) Married
<br /> 6. (b) N�.me of husband or wife �Sary �en�jamin
<br /> 6. ( c) Age of nusband or T�rif e (if alive) 79 t�ears �
<br /> 7, BTRTHDATE OF DECEASED i�Ionth Ju1y Day ��, Year 1�66
<br /> �. AGE OF DECEASED Years �2 Months 9 Days 0 I� less than one day (Hrs. ) - (T•�in. ) -
<br /> 9. BIRTHPLACE OF DECEASED City Zeno State Ohio
<br /> 10. USUAL QCCUPATION (Kind of ,�ob) Bapt�.st M�nister
<br /> 11. INDU5TRY OR BUSINESS: Retired
<br /> Father (12. NamE David Ben,jamin
<br /> (1j. Birthplace Mechanicsville, New York
<br /> DZother( 14. Maiden Name E1.iza ���orkman
<br /> ( 1 . Birthplace Blue Rock, Ohio
<br /> l�. INFORT��iANT Hospi�al Records-J. W. Jones
<br /> P.O. Adc�xess 1753 �°T. Congress,
<br /> Chicago, Illinois
<br /> 17. PLACE OF BURIAL,
<br /> (a) Cemetery Grand Island
<br /> Location Grand Island .
<br /> County Ha�l State Nebraska
<br /> (b} DATE: April 2j 1949
<br /> i 18. FUNERAL DIRECTOR'S '
<br /> Signature T�7. J. Suerth .
<br /> Addre�� �75�- Nort�z�;�e�t Hi�hti�ray - .
<br /> License Number 5060
<br /> � Firm Na.me �2. J. Suerth
<br /> 19. 3nt. List Nur�ber 12�-B
<br /> I MEDICAL CERTIFICATE OF DEATH
<br /> 20. Date of de�.th: b7onth �- day 2j� �-9 year 7 ho r 45 minute A.M.
<br /> 21. I hereby certify that I attended the deeeased from 3�31/�-g, to �-/21/�-9, that I las'� saw
<br /> him alive on 4/zi/49, and th�,t death occurred on the date and hour stated above.
<br /> Imr:ediate c�,use of d�ath Hepat�.c Failure I7ura�ion 7 days
<br /> Associated diseases Cirrhos�.s of Liver 21 days
<br /> Other cond3.tions (Tnclude pre��anc;� within 3 months of de�.th)
<br /> 22. Cti'as an operation performed. No Date of --
<br /> For what disease or in�jury: - -
<br /> Was ther� an �,utopsy: yes
<br /> Findings: as above
<br /> 23. If a comc�un�.ca'ple disea5e,• .��here contrac�ed: No
<br /> ���as di.sease in any way relatec� to occupation of deceased: No
<br /> If so, specify how: No
<br /> 2�-. (Signed) S. G. Taylor M.D.
<br /> I� Ad�ress 122 S. Michigan Ave
<br />� D�te 4/21/�-9 Te7.ephone 1�TA-2-��5�
<br /> N.B.--St�,te the disease causin� dea,'�h. All cases of death from "violence, casualty, or any
<br /> unaue rneans" must be referred to the coroner. See Section 10 Coroner �s Ac�.
<br /> 2�j. FILED Herman N. Bundesen
<br /> (Sign�d) Re�istrar•
<br /> P. 0. Addregs 1� APR �1. �M 7�-
<br /> CITY OF CHICAGO--BOARD OF HEALTH
<br /> STATE OF ILLINOIS) OFFICE OF THE PRESIDEr1T BOAFiD �F HEALTH
<br /> COUNTY OF COOK ) SS T, Herman N. Bundesen, M. D. , �egistrar of Vita1 5tatistics of the
<br /> CITY OF CHICAGO Ci�f of Chicago, do hereby certify that I am the keeper of the
<br /> records of births, s�tillb3.r�hs and deaths of the City of Chicago
<br /> by virtue of the laws of the State of Illino�.s and the ordinances of the City of Chicago;
<br /> that the accompanyin� cer�ificate on this shee� is a true copy of a recor d kept by me in
<br /> pursuance of said laws �,nd ordinances. �
<br /> Herman N. Bundesen ( CORP)
<br /> PRESIDENT OF THE BO,AR,D OF HEALTH, REGI�TRAR ( SEAL) ;
<br /> APRIL 25, 1949 j
<br /> I �
<br /> �'iled for record this 2 day of June 19�-9, at 10:20 0 �clock A.M. � � � ;
<br /> ♦ A,� 4f /��/����
<br /> GY.� ���44 . - vvi��`� I
<br /> ° � egister�of Deeds
<br /> � � o-o-o-o_o-o-o-o-o_o-o_o-o-o-o_o-o-o-o-o-o-o-o-o-o_o-o-o-o_o-o--o-o-o_o-o_o-o-o-o-o-o-a_o-o-o
<br /> �
<br /> -�`'� � � �� � � ��� ;
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