|
z: % r c - ? ,
<br />WASHINGTON STATE DEPARTMENT OF HEALTH
<br />PUBLIC HEALTH STATISTICS SECTION
<br />Certified Copy of
<br />REG.
<br />�-
<br />Certificate
<br />of Death
<br />REGISTRAR'S N 0.13
<br />1J -IJJG
<br />If Under 24 Hrs,
<br />STATE FILE NO.
<br />1. PLACE OF DEATH
<br />a. COUNTY Sno1'lolilish
<br />2. USUAL RESIDENCE (Where deceased lived. If institution: residence
<br />Months) Days
<br />I Hours I Min.
<br />STATE b. COUly� Y before admission.)
<br />W�snington
<br />-
<br />b. CITY (If outside corporate limits, write
<br />OR RURAL and give township)
<br />c. LENGTH OF
<br />STAY (in this place)
<br />I
<br />Jn01ionlish
<br />CITY - --
<br />c. (If outside corporate limits, write RURAL and give town -
<br />OR
<br />TOWN j;ve t
<br />ship)
<br />TOWN
<br />d FULL NAME OF (If not in hossital or
<br />HOSPITAL OR
<br />institution, give street
<br />d. STREET (If rural, give location) - - - - - --
<br />IN ITU
<br />INSTITUTION 252'7 l'l0yt
<br />address or location)
<br />ADDRESS
<br />_
<br />15. Was Deceased Ever
<br />(Yes, no, or unknown)I
<br />2K 97 Iln,rt
<br />3. NAME OF a. (First b. (Middle) c. (Last) 4. DATE
<br />DECEASED (Month) (Day) (Year)
<br />(Tvne or nrinfl 1) nT.nT OF
<br />5. SEX
<br />8. COLOR OR RACE
<br />nin
<br />7. MARRIED, NEVER MARRIED 8. DATE OF BIRTH AGE (In years
<br />t•.L'1SWR-
<br />If Under 1 Yr.
<br />1J -IJJG
<br />If Under 24 Hrs,
<br />llctic�
<br />-Ma lo
<br />-'1"'1 to
<br />19.
<br />DIVORCED last birthday)
<br />(Specify) WjdnwPr March-27-187
<br />Months) Days
<br />I Hours I Min.
<br />Wa. USUAL OCCUPATION (Give kind of
<br />work done during most working
<br />10b. KIND OF BUSINESS OR INDUSTRY
<br />75
<br />11.1. BIRTHPLACE
<br />_
<br />12. CITIZEN OF WHAT
<br />.Off
<br />life, even if retired) Ministe
<br />(State or foreign countrI
<br />Illinois
<br />COUNTRY?
<br />13. FATIiER'S NAME
<br />_
<br />14. MOTHER'S MAIDEAME
<br />No recdrd
<br />N o record
<br />15. Was Deceased Ever
<br />(Yes, no, or unknown)I
<br />in U. S. ARMED FORCES?
<br />(If yes, give war or dates of service)
<br />16. SOCIAL. SECURITY NO.
<br />17. INFORMANT
<br />R.B. Drown
<br />18. CAU5E OF DEATH
<br />Enter only one cause
<br />MEDICAL CERTIFICATION
<br />INTERVAL BETWEEN
<br />per line for (a), (b),
<br />I. DISEASE OR CONDITION
<br />Occlusion
<br />DIRECTLY LEADING TO DEATH- (a) Occlusion and
<br />ONSET AND DEATH
<br />and(c)
<br />..- .....Coronary ......
<br />ANTECEDENT CAUSES
<br />........_.. ........_........__......_..._.
<br />*This does not mean
<br />Morbid conditions, if any, giving Due to (b):......AL'tE.rioscleOrL
<br />the mode of dying,
<br />such as heart failure.
<br />rise to the above cause (a) stat- ...... ...............................
<br />ing the underlying cause last.
<br />................. ...............................
<br />asthenia, etc. It means
<br />'Injury,
<br />Due to (c) . ................ ..... .................................... ...............................
<br />................. ...............................
<br />the disease, or
<br />complication which
<br />II. OTHER SIGNIFICANT CONDITIONS
<br />caused death.
<br />Conditions contributing to the death but not
<br />related to the disease or condition causing death.
<br />19a. DATE OF OPERA-
<br />19b. MAJOR FINDINGS OF OPERATION
<br />TION
<br />20. AUTOPSY?
<br />Yee o Noti
<br />21a. ACCIDENT (Specify)
<br />SUICIDE
<br />21b. PLACE OF INJURY (e.g., in or about
<br />home, farm, factory, street, office bldg., etc.)
<br />21c. (CITY, 'TOWN, OR TOWNSHIP) (COUNTY) (STATE)
<br />HOMICIDE
<br />210. TIME (Month)
<br />OF
<br />(Day) (Year) (Hour)
<br />2le INJURY OCCURRED
<br />21f. HOW DID INJURY OCCUR?
<br />INJURY
<br />I While at Not while
<br />m .
<br />work at work
<br />22. I hereby certify that I attended the deceased from ............ J.i11.Y......, 19.51, to .......... Zi1Z.'.C}1-.. -1-3 ................... 19...5..2 that I last saw the deceased
<br />alive on .................. Mardi .......139 -52, and that death occurred at...1,2. :.Q$mpfrom the causes and on the date stated above.
<br />23a. SIGNATURE (Degree or title) 23b. ADDRESS 23c. DATE SIGNED
<br />H.S.iWestovdr NIU Everett, ?+n. 3 -15 -1952
<br />24a. BURIAL, CREMA-1 24b. DATE 24c. Name of Cemetery or Crematory 124d. LOCATION (City, town, or county) (State)
<br />TION, REMOVAL
<br />(Specify) - .3-1. _ ') Hastings Hastings, Nebraska
<br />DATE REC'D BY LOCAL REGISTRAR'S SIGNATURE 25. FUNERAL DIRECTOR
<br />M REG.
<br />arch -l5 -1952 B H Fnhr Purdy & Waltdrs- Everett Wn. _
<br />I HEREBY CERTIFY, That the foregoing is a true copy of the certificate of death of
<br />................................ Bi"D ORD BROWN
<br />as filed in this office.
<br />•
<br />o }
<br />i
<br />By..............._.. .............
<br />,(, iO EYERETT PRINTING COMPANY 0691 SsverCtt
<br />................ .......
<br />Registrar
<br />- ---- .... ......... . ... .........- . .............. .................................. .------------------
<br />Assistant
<br />Wash.,. .. ................ FCbruiLry .... .2$............. - 19- -SrJ
<br />Filed for record March 3, 195.5, at 9:10 A. M. Yom'.f.�_ ile.ic per of Deeds
<br />Ha.-ll. Co. , Nebr. .
<br />
|