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CERTIFICATE OF DEATH
Nebraska State Department of Heath
Bureau of Vital Statistics
Registered No. 11338
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1 PLACE OF DEATH
County: Nemaha State: Nebraska
Township: London or Village: (blank)
City: Brownville No. (blank) St. (blank) Ward (blank)
2 FULL NAME: John A. Daugherty
(a) Residence No. (blank) St. (blank) Ward (blank)
Length of residence in city or town where death occurred: 47 yrs (blank) mos. (blank) ds.
How long in U.S. if foreign birth? (blank) yrs (blank) mos. (blank) ds.
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PERSONAL AND STATISTICAL PARTICULARS
3 SEX: Male
4 COLOR OR RACE: White
5 Single, Married, Widowed or Divorced (Write in word): Widowed
5a If Married, Widowed, or Divorced
HUSBAND of (or) WIFE of: Margeret Daugherty (deceased)
6 DATE OF BIRTH: June 7 1839
7 AGE: 81 Years 9 Months (blank) Days If LESS than 1 day (blank) hrs. or (blank) min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work: Blacksmith, Farmer
(b) General nature of Industry, business, or establishment in which employed (or employer): (blank)
(c) Name of employer: Self
9 BIRTHPLACE (city or town): Hutsonville (state or country) Crawford Co. Ill
PARENTS
10 NAME OF FATHER: Cornelius Daugherty
11 BIRTHPLACE OF FATHER (city or town) (blank) (State or country) Grayson Co. Kentucky
12 MAIDEN NAME OF MOTHER: Naoma Correll
13 BIRTHPLACE OF MOTHER (city or town) Tazewell Co (State or country) North Carolina
14 Informant: T. C. Daugherty (Son)
(Address) Auburn Nebr
15 Filed: JUN 20 1921 B(?) Registrar
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MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (Month, day, and year): April 4 1921
17 I HEREBY CERTIFY, that I attended deceased from Mar 13, 1920 to Apr 4, 1921 that I last saw him alive on Sep 21, 1920 and that death occurred on the date stated above at (blank) m.
The CAUSE OF DEATH was as follows: Cancer lip (?) of (?) involved (?)
(blank) (duration) (blank) yrs. (blank) mos. (blank) ds.
CONTRIBUTORY (Secondary): (blank) (duration) (blank) yrs. (blank) mos. (blank) ds.
18 Where Was Disease Contracted if Not at Place of Death? (blank)
Did Operation Precede Death? No Date of (blank)
Was There and Autopsy? No
What Test Confirmed Diagnosis? (blank)
(Signed) V. V. Vance, M.D. (blank), 19 (blank) (Address) Peru Nebr.
19 Place of Burial, Cremation, or Removal: Brownville Cemetery
Date of Burial: Apr 5 1921
20 Undertaker: H. E. Furlong
Address: Auburn Nebr. |
Fisher Family Genealogy