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:  Sarah Ann Cole

Personal and Statistical Particulars

Medical Certificate of Death

3 Sex

Female

4 Color

White

5 S/M/W/D

Widowed

16 Date of Death (M/D/Y)

Dec 21, 1926

6 Date of Birth (M/D/Y)

Apr 24,  1829

17 I HERBY CERTIFY, That I attended deceased from

that I saw her     alive  on Dec 21, 1926

and that death occurred on the date above, at 2:30 PM

The cause of death was as follows:  Senile debility and has been

Lingering for years.

Signed:  B. A. Cole, M. D.,, Thorp

Date: 

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

97/7/27

8 Occupation

Housewife

9 Birthplace

Randolph, Portage Cp.

10 Name of Father

Beden Goss

11 Birthplace of Father

18 Length of Residence (Hospitals, etc.)

12 Maiden Name of Mother

Phidelia Cross

13 Birthplace of Mother

Vermont

14 The above is true to the best of my knowledge

Informant:  B. A. Cole, M. D.

Address:  Thorp

19 Place of burial or removal

Woodstock, Wis.

Date

Dec 24, 1926

15  File date - Registrar

Dec 22, 1928   H. C. Conklin

20 Undertaker

Address