1 Place of Death

County: 

Township: 

Village: 

City: 

 

 

STATE OF WISCONSIN

Department of Health – Bureau of Vital Statistics

Original Certificate of Death

                                                Registered No: 

 

2 FULL NAME:  Mabel Moeller

Personal and Statistical Particulars

Medical Certificate of Death

3 Sex

F

4 Color

W

5 S/M/W/D

Married

16 Date of Death (M/D/Y)

May 3, 1935

6 Date of Birth (M/D/Y)

Mar 19, 1897

17 I HERBY CERTIFY, That I attended deceased from

called after death

that I saw h     alive  on 

and that death occurred on the date above, at

The cause of death was as follows:

 

 

 

Signed:  B. A. Cole, M. D.

Date: May 3, 1935  R3 Thorp

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

38/1/14

8 Occupation

Housewife

9 Birthplace

Caledonia, Wis

10 Name of Father

Anton Levin

11 Birthplace of Father

 

18 Length of Residence (Hospitals, etc.)

 

12 Maiden Name of Mother

 

13 Birthplace of Mother

 

14 The above is true to the best of my knowledge

Informant:  B. A. Cole, M.D.

Address:  Thorp, Wis

19 Place of burial or removal

St. Peter’s Cemetery

Date

May 6, 1935

15  File date - Registrar

May 5,               M. R. Smith

 

20 Undertaker

W. P. Kleiner

Address

Boyd, Wis

 

 

 

 

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