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:  1

2 FULL NAME:  Martha Marilla Moore

Personal and Statistical Particulars

Medical Certificate of Death

3 Sex

Female

4 Color

White

5 S/M/W/D

Widowed

16 Date of Death (M/D/Y)

Mar 19, 1921

6 Date of Birth (M/D/Y)

Dec 6, 1848

17 I HERBY CERTIFY, That I attended deceased from

Nov  1920 to Mch 19, 1921

that I saw her     alive  on  Mch 17, 1921

and that death occurred on the date above, at 3:30 AM

The cause of death was as follows:

Chronic Brights Disease

Duration:  I do not know.

Signed:  B. A. Cole

Date:  Mch 19, 1921    Thorp, Wis

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

72/3/13

8 Occupation

Housewife

9 Birthplace

New York

10 Name of Father

Samuel Veeder

11 Birthplace of Father

New York

18 Length of Residence (Hospitals, etc.)

12 Maiden Name of Mother

Martha J. Carnes

13 Birthplace of Mother

New York

14 The above is true to the best of my knowledge

Informant: 

Address: 

19 Place of burial or removal

Town of Forest

Vernon Co., Wis.

Date

15  File date - Registrar

Mch 19, 1921  H. C. Conklin

20 Undertaker

Frank Randall

Address

Augusta, Wis.