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STATE OF ILLINOIS ORIGINAL
Department of Public Health--Division of Vital Statistics
CORONER'S CERTIFICATE OF DEATH
Registered No. 1348
1. PLACE OF DEATH
County of Peoria
Registration Dist. No. 747
Peoria City Primary Dist. No. 3540
Street and Number, No. (blank) St., (blank) Ward, (blank) St. Francis Hospital
LENGTH OF RESIDENCE WHERE DEATH OCCURRED (blank) yrs. (blank) mos. 3 Hrs.
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1a. PLACE OF RESIDENCE: STATE Illinois County Peoria
City or Village Kingston Mines Township Timber
Street and Number (blank) Road Dist. (blank)
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2. FULL NAME Julian Frances Smith
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PERSONAL AND STATISTICAL PARTICULARS
3. SEX Male
4. COLOR OR RACE White
5. Single, married, Widowed, or Divorced Married
5a. If married, widowed, or divorced HUSBAND of (or) WIFE of Florine
6. DATE OF BIRTH January 29th, 1906
7. AGE Years 29 Months 10 Days 18 If LESS than 1 day (blank) hrs. or (blank) min.
8. Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc. Laborer
9. Industry, business in which work was done, as silk mill, saw mill, bank, etc. Tractor Company
10. Date deceased last worked at this occupation (month and year) 12-16-35
11. Total time (years) spent in this occupation 5 mo.
12. BIRTHPLACE (city or town) LaHarpe
(State or country) Illinois
FATHER
13. NAME Thomas Smith
14. BIRTHPLACE (city or town) LaHarpe
(State or country) Illinois
MOTHER
15. NAME Cordelia J. Milton
16. BIRTHPLACE (city or town) Farris
(State or country) Illinois
17. INFORMANT Florine Smith
P.O. Address Kingston Mines, Ill.
18. PLACE OF BURIAL, Cremation or Removal
Cemetery Good Hope
Location Good Hope Illinois
County McDonough State Illinois
19. DATE Dec. 19, 1935
20. UNDERTAKER Ronald G. Howard
Howards Funeral Home ADDRESS Glasford, Illinois
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CORONER'S CERTIFICATE OF DEATH.
21. DATE OF DEATH December 17th, 1935
22. I HEREBY CERTIFY That I took charge of the remains of the deceased herein described, held at Inquest thereon and from the evidence obtained find that said deceased came to his death on the date stated above and that Disease or Injury causing Death was: Third degree burns of the entire body.
Date of Onset of Occurrence: December 17th, 1935
Manner of Injury was: Clothing caught fire while attempting to start fire and kerosene can he was using exploded.
Accidental, Suicidal or Homicidal? Accidental
Was injury in any way related to occupation of deceased? No
If so specify: (blank)
23. Injury rec'd at Timber Township
Specify if injury occurred in industry, in home or in public place: At Home
24. (Signed) Wm B. Elliott Coroner
By (blank)
Address Peoria, Illinois
Date Dec 17th, 1935 Telephone (blank)
25. Filed 12-18, 1935 Mildred Williams Registrar
P.O. Address Peoria Il.
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Has decendent ever served in military or naval service of U.S. No. |
Fisher Family Genealogy
