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:  2

2 FULL NAME:  John Fred Warden

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)

Nov 27, 1919

6 Date of Birth (M/D/Y)

May 19, 1901

17 I HERBY CERTIFY, That I attended deceased from

that I saw him alive  on Nov 27, 1919

and that death occurred on the date above, at 6-15 PM

The cause of death was as follows:

Gun shot in the head.  He lived about 3 or 4 hours after being

Injured.

Died at residence of W. C. Butler

Signed:  B. A. Cole

Date: Nov 27, 1919 - Thorpe

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

8/6/8

8 Occupation

Laborer

9 Birthplace

Meeker Co. Minn.

10 Name of Father

John Warden

11 Birthplace of Father

18 Length of Residence (Hospitals, etc.)

12 Maiden Name of Mother

Clara Belden

13 Birthplace of Mother

14 The above is true to the best of my knowledge

Informant:  Mother

Address: 

19 Place of burial or removal

Butler Cemetery

Date

Nov 30, 1919

15  File date - Registrar

Nov 28, 1919 - H. C. Conklin

20 Undertaker

John Bogumil

Address

Thorpe