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:  3

 

2 FULL NAME:  Elsie Marie Nichols

Personal and Statistical Particulars

Medical Certificate of Death

3 Sex

Female

4 Color

White

5 S/M/W/D

Married

16 Date of Death (M/D/Y)

Feb 17, 1920

6 Date of Birth (M/D/Y)

Sept 18, 1894

17 I HERBY CERTIFY, That I attended deceased from

Feb 9th 1920 to Feb 16 1920

that I saw her     alive  on Feb 16, 1920

and that death occurred on the date above, at 12 PM

The cause of death was as follows:

Effects of cold followed by pleurisy.  Duration 7 Days.

 

 

Signed:  B. A. Cole

Date: Feb 17, 1920  Thorpe, Wis.

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

25/7/29

8 Occupation

Housewife

9 Birthplace

Madison, Wis.

10 Name of Father

Antone Beyler

11 Birthplace of Father

Wis.

18 Length of Residence (Hospitals, etc.)

 

12 Maiden Name of Mother

Anna Beyler

13 Birthplace of Mother

Madison, Wis.

14 The above is true to the best of my knowledge

Informant:  B. A. Cole

Address: 

19 Place of burial or removal

Madison, Wis.

Date

15  File date - Registrar

Feb 18, 1920   H. C. Conklin

 

20 Undertaker

 

Address

 

 

____________________________________________________

THIS “STUB” TO BE KEPT BY PERSON ISSUING PERMIT

 

______

 

BURIAL PERMIT

______

 

1.  Name of deceased:  Elsie Marie Nichols

 

2.  Place of burial:  Madison, Wis.

 

3.  Date and place of death: 

 

4.  Disease causing death:  effects of cold followed by pleurisy

 

5.  Cause of death given by:  Stated above

 

 

6.  Undertaker: 

 

 

 

 

 

 

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