1 Place of Death

County:  Clark

Township:  Butler

Village: 

City: 

STATE OF WISCONSIN

Department of Health - Bureau of Vital Statistics

Original Certificate of Death

                                                Registered No:  1

2 FULL NAME:  Duance Edmond Shoemaker

Personal and Statistical Particulars

Medical Certificate of Death

3 Sex

Male

4 Color

White

5 S/M/W/D

Single

16 Date of Death (M/D/Y)

Oct 10, 1918

6 Date of Birth (M/D/Y)

January 23, 1917

17 I HERBY CERTIFY, That I attended deceased from

Oct 7, 1918 to Oct 10, 1918

that I saw him alive  on Oct 10, 1918

and that death occurred on the date above, at 6-10  PM

The cause of death was as follows:

Cold and influenza.

Signed:  B. A. Cole

Date: Oct 10, 1918 Thorpe, Wis.

7 Age (Yrs/Mos/Ds/Hrs/Min)

1/8/17

8 Occupation

9 Birthplace

Butler Clark Co., Wisc

10 Name of Father

Carl Lincoln Shoemaker

11 Birthplace of Father

Greenwood, Wisc.

18 Length of Residence (Hospitals, etc.)

12 Maiden Name of Mother

Olive Velma Langley

13 Birthplace of Mother

Greenwood, Wisc.

14 The above is true to the best of my knowledge

Informant:  B. A. Cole, M. D.

Address:  Thorpe, Wisc.

19 Place of burial or removal

Butler Cemetery

Date

Oct 12, 1918

15  File date - Registrar

Oct 12 1918 - Arthur J. Field

20 Undertaker  Person in charge

B. A. Cole, M. D.

Address

Thorpe, Wis.