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Note: N3886 Sex (female) and status (died as infant) from the obituary of Leanna F. Bristor - "Observer-Reporter" newspaper, Washington, Washington County, Pennsylvania, Sunday, March 29, 1998 (page D-10)
--------------------
COMMONWEALTH OF PENNSYLVANIA.
BUREAU OF VITAL STATISTICS.
CERTIFICATE OF DEATH.
File No. __ 12445 ___
Registered No. __ 11 __
Registration District No. __ 900 __
Primary Registration District No. __ 3416 __
PLACE OF DEATH.
County of ___ Washington ___
Township of ___ East Finley ___
or
Borough of __________
or
City of __________ (No. ____, __________ St.; __________ Ward)
[If death occurs away from
USUAL RESIDENCE
give facts called for under
ÒSpecial Information.Ó]
[If death occurred in a
Hospital or Institution,
give its NAME instead
of street and number.]
FULL NAME ___ Died Unnamed ___
PERSONAL AND STATISTICAL PARTICULARS
SEX ___ Female ___
COLOR ___ White ___
DATE OF BIRTH ___ Feby ___ (Month) ___ 10 ___ (Day) ___ 1910 ___ (Year)
AGE __ - __ years, __ - __ months, __ - __ days
SINGLE, MARRIED,
WIDOWED, OR DIVORCED ___ Stillbirth (lined out) ___
BIRTHPLACE
(State or country) ___West Finley (lined out) Pa. R.D.#1 (lined out) ___
NAME OF
FATHER ___ Geo Francis ___
BIRTHPLACE
OF FATHER
(State or country) ___ Penna ___
MAIDEN NAME
OF MOTHER ___ Josephine Porter ___
BIRTHPLACE
OF MOTHER
(State or country) ___ Penna ___
OCCUPATION ___ Ñ ___
THE ABOVE STATED PERSONAL PARTICULARS ARE TRUE
TO THE BEST OF MY KNOWLEDGE AND BELIEF
(Informant) ___ Geo Francis ___
(Address) ___ West Finley Pa R.D.#1 ___
15. Filed ___ 2-11- ___ 190 _ 10 _
____ C C Cracroft ____
Registrar
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH ___ Feby ___ (Month) __ 10 __ (Day) 190 _ 10 _ (Year)
I HEREBY CERTIFY, That I attended deceased from
___ Ñ- ___ 190 __, to ___ Ñ- ___ 190 __
that I last saw h __ - __ alive on ___ Ñ- ___ 190 __
and that death occurred, on the date stated above, at ___ 11.00 ___
__ P. __ M. The CAUSE OF DEATH was as follows:
____________________
___ Still birth ___
___ 500 ___
__________ (Duration) ______ Days
Contributory ___________________
__________ (Duration) ______ Days
(Signed) ___ John H. Cary ___ M. D.
___ Feby 10 ___ 190 _ 10 _ (Address) ___ Prosperity Pa ___
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or
Recent Residents.
Former or
Usual Residence __________
How long at
Place of Death? ______ Days
Where was disease contracted? __________
PLACE OF BURIAL OR REMOVAL ___ Fairmont ___
DATE OF BURIAL ___ Feby 12 ___ 190 _ 10 _
20. UNDERTAKER ___ Geo Francis ___ ADDRESS ___ West Finley R.D.#1 ___
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
CAUSE OF DEATH in plain terms, that it may be properly classified. The ÒSpecial InformationÓ for persons dying away
from home should be given in every instance.
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