David Smith Hepner Death Certificate

STANDARD CERTIFICATE OF DEATH

State Department of Health

Division of Vital Statistics

STATE OF IOWA

1. PLACE OF DEATH:

County: Cedar

State: Iowa

Registered No.: [blank]

Township: Center

or Village: [blank]

City: Tipton

No. [blank] St., [blank] Ward

Length of residence in city or town where death occurred: 23 yrs, [blank] mos. [blank] ds.

How long in U.S. if of foreign birth? [blank] yrs. [blank] mos. [blank] ds.

2. FULL NAME: David Smith Hepner

(a) Residence: No. Tipton Town. St., [blank] Ward

PERSONAL AND STATISTICAL PARTICULARS:

3. SEX: M.

4. COLOR OR RACE: W.

5. Single...: Widowed<BR>

5a. If married, widowed, or divorced HUSBAND of (or) WIFE of: Mary Jane Hepner

6. DATE OF BIRTH: Mar 5, 1842

7. AGE: 93 years, 11 months, 7 days

OCCUPATION:

8. Trade...: Retired Farmer

9. Industry...: [blank]

10. Date deceased last worked at this occupation (month and year): [blank]

11. Total time (years) spent in this occupation: [blank]

12. BIRTHPLACE: Ohio

FATHER:

13. NAME: Mathias Hepner

14. BIRTHPLACE: Germany

MOTHER:

15. MAIDEN NAME: Mary Turnpaio

16. BIRTHPLACE: [blank]

17. INFORMANT: Mrs. Chas. A. Baker

(Address): Tipton, Ia.

18. BURIAL, CREMATION, OR REMOVAL:

Place: Tipton

Date: Feb 15, 1936

19. LICENSED EMBALMER: Fred Newton

No. 2363

(Address) Tipton, Ia.

20. FILED [blank], 19[blank]

Registrar: [blank]

MEDICAL CERTIFICATE OF DEATH:

21. DATE OF DEATH: Feb 12, 1936

11. I HEREBY CERTIFY, That I attended deceased from [blank], 19[blank] to [blank], 19[blank], I last saw h[blank] alive on [blank], 19[blank], death is said to have occurred on the date stated above, at 4:30 P.M. The principal cause of death and related causes of importance in order of onset were as follows:

Senile Disability

Date of onset: [blank]

Contributory causes of importance not related to principal cause: [blank]

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: [all blank]

24. Was disease or injury in any way related to occupation of deceased? [blank]

If so, specify: [blank]

(Signed) W. A. Blodgett, D.C.P.M.

(Address) Tipton, Ia.