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MINNESOTA DEPARTMENT OF HEALTH
<br />omes
<br />Section of Vital Statistics
<br />lent
<br />i STATE FILE NUMBER
<br />CERTIFICATE OF DEATH
<br />ord.
<br />LOCAL FILE NUMBER
<br />2 SEX
<br />�. DATE OF DEATH Mo p.Y Y"•r
<br />1pe,
<br />;rma•
<br />FIRST MIDDLE LAST
<br />1 . DECEASED - NAME
<br />SCHMI DfI
<br />Male
<br />[�QQ
<br />June 13, 17CJ0
<br />WIILI AM p, ,
<br />6 RACE (Soec�fy)
<br />t• COUNTY OF DEATH
<br />4a. AGE (In Y•ers
<br />Last Birthday)
<br />4b. Under One Yur
<br />onths ay+
<br />4c. Vrde' One Dav 5 DATE OF BIRTH Mo. Day v ear
<br />o,r,s -u"t Marl:h 8, 1923
<br />Caucasian
<br />,
<br />R�TLSe •.
<br />A.
<br />65
<br />HOSPi .AL OR OTHER INSTITUTION - N.m• lIf not m •.tn•r.and"Numb.)
<br />OPIEMPf. Rmt.Iingal enit 5pe�y)
<br />ih. LOCATION OF DEATH (City a1 Off^*e"*I tc
<br />Bethesda Hospital
<br />in anent
<br />City of Saint Paul
<br />10, Mafn•d, N•va' MarrlM, W.duwad•
<br />1SPOUSE -NAME
<br />1.
<br />B. BIRTHPLACE (Sate of Foreign Country)
<br />9. Cit.-tan of What Country
<br />01v0,ced tSPOCOY)
<br />married
<br />Bett Me Schmidt
<br />Minnesota
<br />U.S.A.
<br />14• USUAL OCCUPATION IG. "kind of work dur Doh KIND OF BUSINESS OR INDUSTRY
<br />1Z.W•a OKMMtl ewr in US Afrned 13. SOCIAL SECURITY NUMBER inq most of wOri,.nq Ill. •van if ref rod) _ Bur. lin L On -Nor the
<br />Y" at No) Mechinical En in i
<br />Farce• (SP•c'fY
<br />475_14-35b5 a er -
<br />.
<br />1Stl. Ins.tl• COrpb/•te
<br />no
<br />1'Sa. RESIDENCE - s rATE
<br />15b COUNTY lSc CITY, VIL
<br />City of Rosevi..11e
<br />Limits Soec.fY
<br />vof ❑ NQ
<br />Minnesota
<br />Ramsey Street and Numher Pb/t office
<br />1t ADDRESS OF DECEDENT
<br />18r. FATHER- NAME
<br />Schmidt
<br />16b. BIRTHPLACE IStato0, Fo,ugn
<br />Minnesota`o,ntiy)
<br />17 9� N. Chatsworth - Roseville, MN 55113
<br />William A.
<br />Add'. is } atsworth
<br />q
<br />-�--
<br />18e MOTHER - MAIDEN NAME
<br />lift, BIRTHPLACE IStaI•o, Fo,•'an
<br />Count'yl
<br />•
<br />19 INFOR(M�jANT- NAME ` { t �y(�( j
<br />airs William �a1Y� A• JC`-nld`-' - Roseville, ML N 55113 I•^
<br />1
<br />Elsie Cnright
<br />Minnesot_�,
<br />•-
<br />IF OIAGf.OSISOEFERRkD
<br />ApPrO••met•Inlrrr•1
<br />l7
<br />_
<br />20. PART I - DEATH WAS CAUSED By -- (En'•' only Onr Cute Per I.na IA). (a) and IC) 1 Ch..:k 00. Botw••n 4n+•1 end Death
<br />cc
<br />A. IMMEOIATE CAUSE
<br />N
<br />METASTATIC RECTAL CARCINOMA ---
<br />LL
<br />0
<br />17r
<br />B DUE TO. ON AS A
<br />CON4fOU(4CE Of
<br />C DUIE to, on AS A
<br />NI
<br />CoNst utNct OF
<br />-- -- to AUTOPSY 71t, U res weret.ndl^y+con
<br />def•4`T•n•n4efue4 of
<br />Spe• ,ee s.det•A .n
<br />PART 11 - OTHRt R SIGNIFICANT (CONDITIONS n V is :q NO ge•ln
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<br />is �� if •
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<br />�.�.,�..._...._ MIA li_ elf `` /,1 {� J♦�' Paul, i�li� 55104
<br />140 0At( Of gtt H1A%to4 Chi MAl""o jha«r Lif+1( L COM t;s •••.."• S.J� N • J �I 1 I�€l�y fiVlr • - �• a �.-..
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<br />„•,�, N w. 19��a
<br />cops► of the record an file with the Divisive
<br />r4rtii'Led t to be a true wid correct
<br />St. Pauli Minnesot:+►A►
<br />of Public t•I'eaiths, City of
<br />of Minnesota. Statute 144e•192� and Regulations
<br />ic�na► ehov�ri made und:Wi alsih�??rity
<br />of State Boaarl of Health. ,
<br />this 17th day of Sun® X9 $8
<br />(Signed,SC��'�� - —�
<br />Registraro Vital Statistics
<br />puty
<br />
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