Thelma Jewel BOLIN (Hepner) Death Certificate

STATE OF ILLINOIS

MEDICAL CERTIFICATE OF DEATH

REGISTRATION DISTRICT NO. 16.10

REGISTERED NUMBER: [blank]

STATE FILE NUMBER: 617041

1. DECEASED- NAME: Jewel Moore

2. SEX: Female

3. DATE OF DEATH: June 18th., 1972

4. RACE: White

5a. AGE: 68

5b. UNDER 1 YEAR: [blank]

5c. UNDER 1 DAY: [blank]

6. DATE OF BIRTH: May 27, 1904

7a. PLACE OF DEATH: [COUNTY] Cook

7b. CITY, TOWN, OR ROAD DISTRICT NUMBER: Chicago

7c. INSIDE CITY: YES

7d. HOSPITAL OR OTHER INSTITUTION-NAME: Municipal Tuberculosis Sanitarium

8. BIRTHPLACE: Paragon, Indiana

9. CITIZEN OF WHAT COUNTRY? U.S.A.

10. Divorced

11. NAME OF SURVIVING SPOUSE: [blank]

12. SOCIAL SECURITY NUMBER: 354-22-7837-A

13a. USUAL OCCUPATION: Waitress

13b. KIND OF BUSINESS OR INDUSTRY: Restaurant

13c. U.S. WAR VETERAN: No

13d. WAR OR DATES OF SERVICE: [blank]

14a. RESIDENCE: [STATE] Illinois

14b. [COUNTY] Cook

14c. [CITY, TOWN, TWP, OR ROAD DISTRICT NO.: Chicago

14d. INSIDE CITY: Yes

14e. STREET AND NUMBER: 1151 W. Adams St.

15. FATHER-NAME: James Bolin

16. MOTHER-MAIDEN NAME: Lettie Virt

17a. INFORMANT'S SIGNATURE: Rosemary Flaherty, RN

17b. RELATIONSHIP: Hospital Records

17c. MAILING ADDRESS: 5601 N. Pulaski Rd., Chicago, Ill. 60646

18. DEATH WAS CAUSED BY:

PART I. IMMEDIATE CAUSE

(a) Pulmonary Tuberculosis, Far Advanced, Active

APPROXIMATE INTERVAL BETWEEN ONSET AND DEATH: 1 Year

PART II. OTHER SIGNIFICANT CONDITIONS: [blank]

19a. AUTOPSY: No

19b. If YES...: [blank]

20a. DATE OF OPERATION, IF ANY: [blank]

20b. MAJOR FINDINGS OF OPERATION: [blank]

I ATTENDED THE DECEASED FROM:

21a. June 2nd., 1972

TO

21b. June 18, 1972

21c. AND LAST SAW HIM/HER ALIVE ON: June 18th., 1972

21d. HOUR OF DEATH: 10:30 p.m.

I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THIS DEATH OCCURRED ON THE DATE, AT THE TIME AND PLACE, AND FROM THE CAUSE(S) STATED

22a. SIGNATURE: A. S. Blust, M.D. (Dr. Blust)

22b. DATE SIGNED: June 19th., 1972

22c. ILLINOIS LICENSE NUMBER: 30646

23. MAILING ADDRESS-CERTIFIER: 5601 North Pulaski Road, Chicago, Illinois 60646

24a. BURIAL, CREMATION, REMOVAL: Burial

24b. CEMETERY OR CREMATORY-NAME: Oakridge

24c. LOCATION: Hillside, Illinois

24d. DATE: June 21, 1972

25a. FUNERAL HOME: Mid-City Funeral Home, 10 South Sangamon Street, Chicago, Illinois 60607

25b. FUNERAL DIRECTOR'S SIGNATURE: E. Richard Osman

25c. FUNERAL DIRECTOR'S ILLINOIS LICENSE NUMBER: F-3804

26a. LOCAL REGISTRAR'S SIGNATURE: Murray C. Brown

CHICAGO BOARD OF HEALTH

Chicago Civic Center, Room 105

Concourse Level, Chicago 60602

26b. DATE REC'D BY LOCAL REGISTRAR: JUN 20 1972