1 Place of Death

County:  Clark

Township:  Butler

Village: 

City: 

 

 

STATE OF WISCONSIN

Department of Health – Bureau of Vital Statistics

Original Certificate of Death

                                                Registered No:  2

 

2 FULL NAME:  Alexandria Buchanan

Personal and Statistical Particulars

Medical Certificate of Death

3 Sex

Male

4 Color

White

5 S/M/W/D

Single

16 Date of Death (M/D/Y)

Dec 2, 1925

6 Date of Birth (M/D/Y)

June 9, 1851

17 I HERBY CERTIFY, That I attended deceased from

 

that I saw h     alive  on 

and that death occurred on the date above, at

The cause of death was as follows:

He was found dead in bed.

 

 

Signed:  B. A. Cole, M. D.

Date: Dec 3, 1925     Thorp

7 Age (Yrs/Mos/Ds/Hrs/Min)

74/6/9

8 Occupation

Farming

9 Birthplace

United States

10 Name of Father

Unknown

11 Birthplace of Father

Unknown

18 Length of Residence (Hospitals, etc.)

 

12 Maiden Name of Mother

Unknown

13 Birthplace of Mother

Unknown

14 The above is true to the best of my knowledge

Informant:  Mrs. Clara Gisse

Address:  Thorp, Wis.

19 Place of burial or removal

Butler Cemetary

Date

Dec 4, 1925

15  File date - Registrar

Dec 4 1925     H. C. Conklin

 

20 Undertaker

H. Cummins by H. C. Conklin

Address

Stanley

 

Contributor: Paul Forster.

 

 

 

 

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