Death CertificateTypeOPnnt
N pemu'ant
Black Mk
MINNESOTA DEPARTMENT OF HEALTH
Section of Vital Statistlea
re•eerronwTG /1G nc ATLI
Middle
0 py
erne
1b Alias
2. Soc al Security No.
3 Sex
4 Date of Death
5 Dale of Birth 60 Age (in years)
1Fi°" t lU 7 Placa of Birth (dry and statelforegn country)
Oeme aq
March 10 1915
82 Fathers Name (fist, middle) Bb FaUefs Last Name
9 Mothers Name (first, middle, maiden surname)
Sequentially fist corid'niorls, if arty,
FdwnrdGalena
10 Race
11anhep nie Origin iib If Yes. Specify Cuban, Meriean, Oct...
12a Pnmaryr5scondary1(a12)
IF.
White
XNo Yes '
8
13. Marilial Status
13b Name of Spouse (d wifO, specify maiden name)
14 Decedent's Usual Occupation
_Div. X_Wid. _Never Mar.
rl conditions contributing to death
Auto Technician
151Gnd of Business or Industry
16 U.S. Veteran
17a State of Residence
17b County of Residence
Auto Repair
' No ''ea
:;N
pin
17c City or Township of Residerlca
17d Address of Decedent (number. street, zip)
St Loub Park 17500
West 22nd Street55426
17e Residence in City or Tovwrshlp
i8a City or Township of Death _ 18b County of Death
_X_Cily Limas _Tavnship Limits
St. Lliruil, Park Hennertin
19a Place of Death (specify one) bpec ry - -,
�,Nosp $NH Res Other Jnpatienl _ER _DOA _Other
19c Placa of Faegity Where Death Occurred in nor 1=11uhon, specify, street address)
Fa
26a
12
death. Do rwr eMardu mode of dyina, such ss cardiae a
44d
in
; 27b L. No. nD.
#3058 3
29c License No.. of CertifiIer
Miigf tte 99
K)aSS.
Yes
44e Time of Injury
44f Injury at Work
Yes _ Nc
;d a
34 PART I Enter the diaries, in)ur or oompiketlom con caused
IMMEDIATE cause of death (Orrelhllure
Ny on/s cause per Iinw
disease or condition resulting In
death)
Sequentially fist corid'niorls, if arty,
dleading to immediate ease. Euler b.
} UNDERLYING cause last, (disease
F- or injury that initiated events
N resulting in death). c'
tu 351 avended the a«eased ham � �e eC to
arN tut saw niM
W
� 366 PART II OlharaignUtartt
rl conditions contributing to death
but nor resul ing in the underlying
cause given in Part 1. 37 Was Female P
nand: At Death? Yea
4a M.ElComner Notified
41Aulopsy
39 MANNER OF DEATH lural
�Yes_0K
Yes
44a Place of Injury (stree tt numl
MUST
_Accident
BE
_Homicide
REFERRED_Suicide
44b Describe How Injury Occurred
TO
M.E. or
_Pending lies.
CORONER
_Cannot be Det.
44c Type of Place Where Injury0
Not Classifiable
12
death. Do rwr eMardu mode of dyina, such ss cardiae a
44d
in
; 27b L. No. nD.
#3058 3
29c License No.. of CertifiIer
Miigf tte 99
K)aSS.
Yes
44e Time of Injury
44f Injury at Work
Yes _ Nc