|
, I. PLACE OF DEATH
<br />a. COUNTY
<br />, Snohomish
<br />2. USUAL RESIDENCE (Where deceased lived. If institution: residence before
<br />a. STATE b. COUNTY admission.)
<br />Washington Snohomish
<br />%,.._ b. CITY (II outside corporate limits, write RURAL
<br />OR and give township)
<br />TOWN Everett
<br />c. LENGTH OF
<br />STAY (in this place)
<br />2 Yrs '''
<br />C. CITY (If outside corporate limits, write RURAL and give townehip)
<br />OR
<br />TOWN Everett
<br />0 d. FULL NAME OF (If not in hospital or institution, give street address
<br />HOSPITAL OR or location)
<br />INSTITUTION 2527 Hoyt Ave
<br />d. STREET (If rural, give location)
<br />ADDRESS
<br />2527Hoyt Ave.
<br />3. NAME OF a. (First) b. (Middle)
<br />DECEASED
<br />(Type or print) James Bedford Br
<br />c. (Last)
<br />nwn.
<br />- -
<br />4. DATE • (Month) (Day) (Year)
<br />OF
<br />DEATH 3/13/52
<br />5. SEX 6. COLOR OR RACE
<br />..44
<br />g [ . le Wh i t., R
<br />7 MARRIED, NEVER MARRIED.
<br />WIDOWED. DIVORCED
<br />(S Wi d °wpm
<br />1 8. DATE OF BIRTH
<br />1
<br />1 3/27/1 R 7R
<br />9. AGE (In yearsl
<br />last birthday)
<br />75
<br />If Under
<br />1 Months
<br />1 Yr.
<br />Days
<br />If Under 24 Hrs.
<br />Hours 1 Min.
<br />Oa. USUAL OCCUPATION (owe kind of 10b. KIND OF BUSINESS OR
<br />e" work done during most of working INDUSTRY
<br />life, even if retired) Minis ter
<br />11. BIRTHPLACE (State or foreign country) 12. CITIZEN OF WHAT
<br />courrrurt
<br />JacsonvtlleIllinoiJ U_S,
<br />3. FATHER'S NAME
<br />Robert Brown
<br />14. MOTHER'S MAIDEN NAME
<br />Anna E.Barro-vvs 2 0 I
<br />5, WAS DECEASED EVER IN U. S. ARMED FORCES?
<br />or Unknown)I (If yes, give war or dates of service)
<br />16. SOCIAL SECURITY
<br />NO.
<br />17. INFORMANT
<br />R,B,Brown 2527 Hoyt Ave, Bverett
<br />8. CAUSE OF DEATH
<br />• nter only one cause per
<br />ne for (a). (b). and (c)
<br />1VIEDICAL CERTIFICATION ..
<br />1. DISEASE OR CONDITION
<br />DIRECTLY LEADING TO DEATH* (a)...e.4 .... .............. .. ...... .....
<br />ANTECEDENT CAUSES
<br />h eff
<br />Morbid conditions, if any, giving Due to ( 44,424:04.eiete4.6.4
<br />rise to the above cause (a) stat-
<br />ing the underlying cause last.
<br />Due to (c)
<br />INTERVAL BETWEEN
<br />ONSET AND DEATH
<br />4
<br />This does not mean
<br />It he mode of dying, such
<br />s heart failure, asthenia,
<br />, c. It means the dis-
<br />ase, injury, or com-
<br />Sw ication which caused
<br />k . ath.
<br />,
<br />II. OTHER SIGNIFICANT CONDITIONS
<br />Conditions contributing to the death but not
<br />related to the disease or condition causing death.
<br />,,,
<br />iaa. DATE OF OPERA
<br />TION
<br />19b. MAJOR FINDINGS OF OPERATION
<br />20. AUTOPSY?
<br />Yes 0 No 0
<br />la. ACCIDENT (Specify)
<br />SUICIDE -
<br />HOMICIDE
<br />21b. PLACE OF INJURY (e.g., in or about
<br />home, farm. fac ory, street, office bldg., etc.)
<br />21c. (CITY, TOWN, OR TOWNSHIP) (COUNTY) (STATE)
<br />d. TIME (Month) (Day) (Year) (Hour)
<br />OF
<br />INJURY m.
<br />21e. INJURY OCCURRED
<br />While at r Not while I
<br />work .--, at work .---J
<br />21f. HOW DID INJURY OCCUR?
<br />SaiNt
<br />) c
<br />Or HEN
<br />............ .......
<br />..................
<br />. ................ .............. ... ...... . . . . . . .. . . ... . 4,, _ 1,1
<br />T S A SnEtRilll F,I E00(.'; P YNOT...be R (31N•F...111_ Ej,-VJ E P. S TvAT G.S EiD f.14`Sir H`A raF L S E
<br />G. DIST. NO,
<br />REGISTRAR'S' NO.
<br />NATURE
<br />t
<br />AbiLe4.4rit
<br />4a. BURIAL, CREMA- I 24b. DATE
<br />WASHINGTON STATE DEPARTMENT OF HEALTH
<br />,PUBLIC HEALTH STATISTICS SECTION
<br />CERTIFICATE OF DEATI1
<br />STATE FILE NO.
<br />2 0 1 21
<br />5132
<br />24c. NAME OF CEMETERY OR CREMATORY 24d. LOCATION (C)ty, town, or county) (State)
<br />-T(Specify) v al 3 15 52 Hastin Nebraska
<br />ATE REC'D BY LOCAL REGIER' IG ATURE
<br />REG
<br />1 25, FUNERAL DIRECTOR
<br />Purdy and waiters Everett
<br />ADDRESS
<br />MAR 2 4 190
<br />19 k,
<br />2. 1 hereby certify that I attended the deceased , to 3 ,19 , that I last saw the deceased
<br />fro
<br />alive MT, 3/15/52 19 and that death occur red a 12:0rEtffrom the causes and on the date stated above.
<br />3a.
<br />(Degree or title) 23b. ADDRESS
<br />M.D. Med.& Dent. Bldg.Everet 3/14/52
<br />l 23c. DATE SIGNED
<br />
|