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Note: N3469 Given name (George), middle name (Edward), surname (Francis) and status (died in childhood) from the obituary of Leanna F. Bristor - "Observer-Reporter" newspaper, Washington, Washington County, Pennsylvania, Sunday, March 29, 1998 (page D-10)
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COMMONWEALTH OF PENNSYLVANIA.
DEPARTMENT OF HEALTH
BUREAU OF VITAL STATISTICS.
File No. __ 80894 __
Registered No. __ 39 __
CERTIFICATE OF DEATH
Registration District No. __ 900 __
Primary Registration District No. __ 3416 __
1. PLACE OF DEATH
County of ___ Wash. ___
Township of ___ E. Finley ___
or
Borough of __________
or
City of __________ (No. ____, __________ St., __________ Ward.)
[If death occurred in a
Hospital or Institution,
give its NAME instead
of street and number.]
___ 62-9 ___
2. FULL NAME ___ George Edward Francis ___
PERSONAL AND STATISTICAL PARTICULARS
3. SEX ___ Male ___
4. COLOR OR RACE ___ White ___
5. SINGLE, MARRIED, WIDOWED
OR DIVORCED (Write the word.) ___ Single ___
6. DATE OF BIRTH ___ Feb. ___ (Month) ___ 14 ___ (Day) 1 __ 916 __ (Year)
7. AGE __ 0 __ yrs. __ 6 __ mos. __ 5 __ ds.
IF LESS than 1 day
how many ___ hrs. or
___ min.?
8. OCCUPATION
(a) Trade, profession, or,
particular kind of work ___ --- ___
(b) General nature of industry,
business or establishment in
which employed (or employer) __________
9. BIRTHPLACE
(State or Country) ___ Penn. ___
PARENTS
10. NAME
OF FATHER ___ George Francis ___
11. BIRTHPLACE
OF FATHER
(State or Country) ___ Penn. ___
12. MAIDEN NAME
OF MOTHER ___ Josephine Porter ___
13. BIRTHPLACE
OF MOTHER
(State or Country) ___ Penn. ___
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE.
(Informant) ___ Josephine Francis ___
(Address) __________
15. Filed ___ 8-19- ___ 191 _ 6 _
____ C. C. Cracroft ____
Local Registrar
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH ___ August ___ (Month) __ 19 __ (Day) 191 _ 6 _ (Year)
17. I HEREBY CERTIFY, That I attended deceased from
___ Aug 19 ___ 191 _ 6 _, to ___ Aug 19 ___ 191 _ 6 _
that I last saw h __ im __ alive on ___ Aug 19 ___ 191 _ 6 _
and that death occurred, on the date stated above, at ___ 11:30 A ___ M.
The CAUSE OF DEATH* was as follows:
____________________
___ Cholera Infantum ___
____________________
___ 104 ___ (Duration) __ - __ yrs. __ - __ mos. __ 1 __ ds.
Contributory ___________________
(Secondary.)
__________ (Duration) ___ yrs. ___ mos. ___ ds.
(Signed) ___ John H. Cary ___ M D.
___ Aug 19 ___ 19 _ 16 _ (Address) ___ Prosperity Pa. ___
*State the DISEASE CAUSING DEATH; or in deaths from VIOLENT CAUSES, state (1)
MEANS OF INJURY; and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL.
18. LENGTH OF RESIDENCE (For Hospitals, Institutions, Tran-
sients or Recent Residents).
At Place
of death ___ yrs. ___ mos. ___ ds.
In the
State ___ yrs. ___ mos. ___ ds.
Where was disease contracted,
if not at place of death? __________
Former or
usual residence __________
19. PLACE OF BURIAL OR REMOVAL ___ Fairmount Cemetery ___
DATE OF BURIAL ___ 8-20 ___ 191 _ 6 _
20. UNDERTAKER ___ H. H. Brownlee ___ ADDRESS ___ Claysville ___
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