Text |
State of Nebraska
Department of Health-Division of Vital Statistics
CERTIFICATE OF DEATH
G12054
Form 243-6
1. PLACE OF DEATH
County Saline
Township (blank)
City Wilber, Nebr. No. (blank) Street (blank) {If death occurred in a hospital or institution give its NAME instead of street and number.
Length of residence in city or town where death occurred 58 yr. (blank) mo. (blank) da. How long in U.S. if of foreign birth (checkmark) yr. (checkmark) mo. (checkmark) da.
2. FULL NAME William Andrew Percy
1a. Residence: State Nebr. County Saline City Wilber No. (blank) Street (blank)
PERSONAL AND STATISTICAL PARTICULARS
3. SEX Male / 4. COLOR OR RACE White / 5. SINGLE Married Divorced (write the word) Married
5a. If married, widowed or divorced HUSBAND OF/WIFE OF Martha Jane Percy
6. DATE OF BIRTH (mo.) March (day) 15 (year) 1860
7. Age Years 76 / Months 7 / Days 24 / If less than 1 day Hrs. (blank) or Min. (blank)
OCCUPATION
8. Trade, profession or particular kind of work down, as spinner, sawyer, bookkeeper, etc. Painter
9. Industry or business in which work was done as silk mill, saw mill, bank, etc. (checkmark)
10. Date decesaed last worked at this occupation (month and year) Aug. 1936
11. Total time (years) spent in this occupation Lifetime
12. Birthplace {City or Town and State or Country Boston Mass.
13. Name of Father William Henry Percy
14. Birthplace of Father {City or Town and State or Country England
15. Maiden name of Mother Stuart
16. Birthplace of Mother {City or Town and State or Country Scotland
17. INFORMANT Martha Jane Percy (Address) (blank)
18. BURIAL, CREMATION, or REMOVAL
Place Wilber Date Nov. 10, 1936
19. UNDERTAKER Fred Shimerda (Address) (blank)
20. Filed 11/11, 1936 (signed) Wm. ??
MEDICAL CERTIFICATE OF DEATH
21. DATE OF DEATH Wm Andrew Percy Nov 9, 1936
22 I HEREBY CERTIFY, That I attended deceased from Sept 1, 1936, to Nov. 9, 1936
I last saw him alive on Nov 8, 1936, death is said to have occurred on the date stated above at 3:45 a.m.
The principal cause of death and related causes of importance in order of onset were as follows:
Cirrhosis of Liver / Date of Onset IMPORTANT july 1, 36
Contributory causes of importance not related to principal cause:
Diabetis
Name of operation (blank) Date of (blank)
What test confirmed diagnosis? (blank) was there an autopsy? (blank)
23. If death was due to external causes (violence) fill in also the following:
Accident, suicide or homicide? (blank) Date of (blank) 19 (blank)
Where did injury occur? (Specify city or town, county and state) (blank)
Manner of injury (blank)
Nature of injury (blank)
24. Was disease or injury in any way relating to occupation of deceased? (blank)
If so, specify (blank)
(Signed) Henry Hern? M.D.
Address) Wilber, Neb
|