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 FULL NAME:  Robert Dale Mock

Personal and Statistical Particulars

Medical Certificate of Death

3 Sex

M

4 Color

W

5 S/M/W/D

Single

16 Date of Death (M/D/Y)

March 23, 1942

6 Date of Birth (M/D/Y)

Aug

17 I HERBY CERTIFY, That I attended deceased from

that I saw h     alive  on 

and that death occurred on the date above, at

The cause of death was as follows:

Gunshot, shot through chin by rifle fired by brother; homicide

Signed:  Albon W. Overgard

Date: Mar 27, 1942   Stanley, Wis.

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

4

8 Occupation

9 Birthplace

Buffalo County, Wis

10 Name of Father

Fred Mock

11 Birthplace of Father

Chippewa County, Wis.

18 Length of Residence (Hospitals, etc.)

12 Maiden Name of Mother

Ruth Briggs

13 Birthplace of Mother

Buffalo County, Wis.

14 The above is true to the best of my knowledge

Informant: 

Address: 

19 Place of burial or removal

Edison Chippewa Co.

Date

15  File date - Registrar

April 7, 1942      E. J.  Greer

20 Undertaker

Severyn Plombon

Address

Stanley, Wis