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 FULL NAME:  John Jay Elmendorff

Personal and Statistical Particulars

Medical Certificate of Death

3 Sex

Male

4 Color

White

5 S/M/W/D

16 Date of Death (M/D/Y)

Dec 3, 1930

6 Date of Birth (M/D/Y)

Dec 27, 1929

17 I HERBY CERTIFY, That I attended deceased from

that I saw him     alive  on Dec 3, 1930

and that death occurred on the date above, at 1:40 ?M

The cause of death was as follows:

Convulsions following pleuro-pneumonia.

Signed:  B. A. Cole

Date: Dec 3, 1930  Thorp, Wis.

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

0/11/6

8 Occupation

9 Birthplace

Montevista, COL

10 Name of Father

Bernard Elmendorff

11 Birthplace of Father

Thorp, Wis.

18 Length of Residence (Hospitals, etc.)

12 Maiden Name of Mother

Frances Kile

13 Birthplace of Mother

Vernon Co., Wis

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

Butler Cemetary

Date

Dec 5, 1930

15  File date - Registrar

Dec 25, 1930    Myrtle R. Smith

20 Undertaker

H. C. Conklin

Address

Thorp, Wis