May JOHNSON (Martin) Death Certificate

STATE OF ILLINOIS

MEDICAL CERTIFICATE OF DEATH

ORIGINAL: 364

DECEDENT'S BIRTH NO.: [blank]

STATE FILE NUMBER: 41055

REGISTRATION DISTRICT NO.: 16.10

REGISTERED NUMBER: [blank]

1. PLACE OF DEATH:

a. COUNTY: Cook

b. Death took place: INSIDE city limits and in the city, village, or town named at 1c

c. CITY, VILLAGE, OR TOWN: Chicago

d. LENGTH OF STAY IN 1b or 1c: 22 Years

e. NAME OF HOSPITAL OR INSTITUTION: Cook County

f. LENGTH OF STAY IN 1e: 9 days

2. USUAL RESIDENCE:

a. STATE: Ill

b. COUNTY: Cook

c. Residence was: INSIDE city limits and in the city, village, or town named at 2d

d. CITY, VILLAGE, OR TOWN: Chicago

e. LENGTH OF RESIDENCE AT 2c or 2d: 22 years

f. STREET ADDRESS: 2275 N. Lincoln

g. Did decedent reside ON A FARM? No

3. NAME OF DECEASED: May Martin

4. DATE OF DEATH: 6 11 56

5. SEX: Female

6. RACE: White

7. MARRIED...: Widowed

8. DATE OF BIRTH: 5-11-1896

9. AGE: 60

10a. USUAL OCCUPATION: Housework

10b. KIND OF BUSINESS OR INDUSTRY: Own home

11. BIRTHPLACE: Paragon Indiana

12. Citizen of what country? USA

13. FATHER'S FULL NAME: Asa Johnson

14. MOTHER'S FULL MAIDEN NAME: Margaret Mannan

15. Was deceased ever in U.S. Armed Forces? No

16. SOCIAL SECURITY NUMBER: None

17. INFORMANT

a. SIGNATURE: Thomas Durken

b. ADDRESS: Cook County Hospital

c. RELATIONSHIP TO DECEASED: Records

18. CAUSE OF DEATH

PART I. DEATH WAS CAUSED BY:

IMMEDIATE CAUSE. (A): Hypertensive Cardiovascular Disease

INTERVAL BETWEEN ONSET AND DEATH: Unknown

PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING...: [blank]

19. AUTOPSY? No

20. DESCRIBE CIRCUMSTANCES OF INJURY...: [blank]

21. I hereby certify that I attended the deceased from 5-13, 1956, to 6-11, 1956, that I last saw the deceased alive on 6-11, 1956, and death occurred at 5:15 a.m., from the causes and on the date stated above.

DATE: 6-11-56

SIGNED: Geo. W. Bard M.D.

ADDRESS: Cook County Hosp.

PHONE: SE8-2500

22. DISPOSITION, BURIAL-REMOVAL-CREMATION

(DATE): June 14, 1956

CEMETERY: Crown Hill

LOCATION: Indianapolis, Indiana

23. FUNERAL DIRECTOR

FIRM NAME: Drake-Braithwaite Co.

ADDRESS: 2221 N. Lincoln Ave.

Chicago, Illinois

SIGNATURE: David R. Beinecke

LICENSE NUMBER: 3241

24. Received for filing on: JUN 12 1956

(signed) Herman N. Bundesen

54 West Hubbard Street, Chicago 10

CHICAGO BOARD OF HEALTH

LOCAL REGISTRAR