Date of Abstract ___________†††††††† Abstracted by_____________________

 

 

†††††††††††††††††† DEATH RECORD ABSTRACT

 

 

Repository___________________________________________________

Address_____________________________________________________

Source ________________________________Volume_____ Page_______

 

Full Name of Deceased__________________________________________

Maiden name (if wife or a widow) __________________________________

Color ___ Social Security #______________Age at death_______________

Birthdate______________________Birthplace_______________________

Occupation_____________Residence______________________________

Married/Widowed/Single______ Spouse name________________________

Death Location (town/township/county)_____________________________

Residence at Death_____________________________________________

Date and Time of Death__________________________________________

Was deceased ever a US Soldier or Sailor?____________________________

Full name of his father_________________________Birthplace__________

Motherís maiden name_________________________Birthplace__________

 

Cause of Death: Primary__________________Duration________________

†††††††††††††††††††††††† Secondary________________ Duration________________

††††††††††† †††††††††††††Other____________________ Duration________________

Attending Physician______________________ of_____________________

Attended (dates):______________________________________________

Autopsy preformed?_____________________________________________

Physician/Coroner/Justice________________________________________

Residence of last person named ___________________________________

Undertaker_____________________________of_____________________

Place of Burial_________________________________________________

Date of Burial______________Date of Certificate Registration___________

Informant Name________________________Relation to deceased________

Address of previously named person________________________________

Additional information___________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

 

Address of person abstracting this record and other contact and relationship information___________________________________________________

____________________________________________________________

____________________________________________________________