Death Record, Mrs J S (Johanna Beatta) ANDERSON, Rock Island County, Illinois Contributed for use in the USGenWeb Archives Copyright 2000 Cyndie Enfinger ************************************************ Copyright. All rights reserved. http://www.usgwarchives.net/copyright.htm ************************************************ CERTIFICATE AND RECORD OF DEATH Register No. 4534 Rock Island County OF 1. Full Name: Mrs. J. S. Anderson 2. (a) Sex: female (b) Color: White (c) Single - Married - Widowed - Divorced: Married 3. (a) Birthplace: Sweden (b) Date of Birth: Mar. 2, 1843 4. Age: 22 years 9 months 19 days ____ hours. 5. Died on the 21 Day of December 1915 at about 1-15 a.m. 6. Last Occupation (a) Housewife (b) _____ From the Year (c) ________ To the Year ___________ 7. Former Occupation (a) ____________(b) _______________ From the Year (c) ________ To the Year ____________ 8. Place of Death: 1013 17 ave. County of Rock Island 9. How Long in State: 34 10. How Long in U. S. if Foreign Born: 34 11. (a) Name of Father: ________ (b) Birthplace of Father: _________ 12. (a) Maiden Name of Mother: _________ Birthplace of Mother: ______________ The foregoing stated personal particulars are true to the best of my knowledge and belief: 13. Informant: J. S. Anderson Address: Moline, Ill 14. Place of Burial: Riverside Cemetery Date of Burial: Dec. 26 Hour 3 p.m. 15. Undertaker: Rise & Barnard Address: Moline, Ill License 1098 No. 775 Medical Certificate of Couse of Death I Hereby Certify That I attended deceased from Dec. 15 1915 to Dec. 21 1915 that I last saw her alive on the 21 day of Dec. 1915 That death occurred on date stated above, at about 1-15 o'clock a.m., and that to the best of my knowledge and belief the cause of her death was as hereunder written. (a) Cause of Death: Pneumonia (b) Contributory (Secondary) _________________ Duration in Years, Months, Days or Hours: ___________________ Witness my hand this 27th Day of Dec. 1915 (Signature) F. H. Gardner Address: Moline, Ill Filed for Record this 7 day of Mar. 1917. H. B. Hubbard, County Clerk. ============================================================================ File contributed for use in USGenWeb Archives by: Cyndie Enfinger