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Note: N3885 CONFLICTING GIVEN NAME (Irma), middle name (Jane), 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. __ 43393 ___
Registered No. __ 154 __
CERTIFICATE OF DEATH
Registration District No. __ 916 __
Primary Registration District No. __ 1520 __
1. PLACE OF DEATH
County of ___ Washington, ___
Township of __________
or
Borough of __________
or
City of ___ Washington, ___ (No. ____, ___ Washington Hospital ___ St., ___ 5th. ___ Ward)
[If death occurred in a
Hospital or Institution,
give its NAME instead
of street and number.]
2. FULL NAME ___ Erma Jane Francis ___
PERSONAL AND STATISTICAL PARTICULARS
3. SEX ___ Female ___
4. COLOR OR RACE ___ White ___
5. SINGLE, MARRIED, WIDOWED
OR DIVORCED (Write the word.) ___ Single ___
6. DATE OF BIRTH ___ July ___ (Month} ___ 6th. ___ (Day) ___ 1924. ___ (Year)
7. AGE yrs. __ 0 __ mos. __ 9 __ ds. __ 4 __
IF LESS than 1 day
how many ___ hrs. or
___ min.?
8. OCCUPATION
(a) Trade, profession, or,
particular kind of work ___ None. ___
(b) General nature of industry,
business, or establishment in
which employed (or employer) __________
9. BIRTHPLACE
(State or Country) ___ Pennsylvania, ___
PARENTS
10. NAME OF
FATHER ___ George Plants Francis, ___
11. BIRTHPLACE
OF FATHER
(State or Country) ___ Pennsylvania, ___
12. MAIDEN NAME
OF MOTHER ___ Josephine M. Porter, ___
13. BIRTHPLACE
OF MOTHER
(State or Country) ___ Pennsylvania, ___
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE.
(Informant) ___ George P. Francis ___
(Address) ___ Claysville, PennÕa. R. D. # ___
15. Filed ___ 4-11- ___ 19 _ 25 _
____ W. G. Nease ____
Local Registrar
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH ___ Apr ___ (Month) __ 10 __ (Day) 19 _ 25 _ (Year)
17. I HEREBY CERTIFY, That I attended deceased from
___ Apr 5 ___ 19 _ 25 _, to ___ Apr 10 ___ 19 _ 25 _,
that I last saw h __ er __ alive on ___ Apr 10 ___ 19 _ 25 _,
and that death occurred, on the date stated above, at ___ 5.30 P. ___ M.
The CAUSE OF DEATH* was as follows:
___ Retropharyngeal Abscess ___
____________________
____________________
___ 109 ___ (Duration) ____ yrs. ____ mos. __ 30 __ ds.
Contributory ___________________
(Secondary)
__________ (Duration) ___ yrs. ___ mos. ___ ds.
(Signed) ___ J H Cary ___ M. D.
___ Apr 10 ___ 19 _ 25 _ (Address) ___ Washington 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, Transients
or Recent Residents).
At place
of death ___ yrs. ___ mos. __ 6 __ ds.
In the
State ___ yrs. ___ mos. ___ ds.
Where was disease contracted,
if not at place of death? __________
Former or
usual residence ___ East Finley Township. ___
19. PLACE OF BURIAL OR REMOVAL ___ Fairmount Cemetery ___
DATE OF BURIAL ___ 4/12/1925. ___ 19 __
20. UNDERTAKER ___ Warren W. Knowles ___ ADDRESS ___ Claysville, Pa. ___
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