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Register No. 10
2 FULL NAME: Mary B. Fraley
(18a) Residence No.: Town of LeRay St.___________ Ward:________________
(Usual place of abode)
PERSONAL AND STATISTICAL PARTICULARS
3 SEX: F
4 COLOR OR RACE: W
5 SINGLE, MARRIED WIDOWED OR DIVORCED (Write the word): Married
5a IF MARRIED, WIDOWED OR DIVORCED Husband of (or) wife of: Christopher Fraley
6 DATE OF BIRTH: Aug. 6, 1880
7 AGE Years: 57 Months:_______ Days: 6
8 OCCUPATION: housewife
9 BIRTHPLACE: (City or Town) LeRay
PARENTS
10 NAME OF FATHER: Ferdinand Besha
11 BIRTHPLACE OF FATHER: (City or Town) LeRay
(State or Country) NY
12 MAIDEN NAME OF MOTHER: Ann Fitzpatrick
13 BIRTHPLACE OF MOTHER: (City or Town) LeRay
(State or Country) NY
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Christopher Fraley
(Address) Evans Mills, N.Y.
15 Filed Aug. 12, 1937, C M Bowles, Registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH: Aug. 12, 1937
17 I HEREBY CERTIFY, That I attended deceased from ______________, 19__ to __________, 19__
that I last saw h_____ alive on_________________, 19__,
and that death occurred on the date stated above, at ___________M
The cause of death was as follows:
Coronary Thrombosis
Sudden
____________(Duration)________yrs._________mos.__________ds
CONTRIBUTORY________________________________________
____________(Duration)________yrs._________mos.__________ds
18b. Where was disease contracted, or injury sustained if not at place of death?_________________
Did an operation precede death?___________________ Date of_____________________
Was there an autopsy? No
What test confirmed diagnosis?_____________________
(Signed) J. E. Jones? , M.D.
Aug. 12, 1937 (Address) Evans Mills, N.Y.
19 PLACE OF BURIAL, CREMATION OR REMOVAL: Rosiere, N.Y.
DATE OF BURIAL: Aug. 14, 1937
20 UNDERTAKER: (License no.) 5656
W.D. Smith
ADDRESS: Evans MIlls, N.Y.
Burial or transit: Permit Issued by: C. M. Bowles
Date of Issue: Aug. 12, 1937 |
