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CERTIFICATE OF DEATH.
Class No: 11/64
No. of Record: 269103
DISTRICT OF COLUMBIA
1. PLACE OF DEATH:
No. 1505 11th Street, N.W. Section
Name of Hospital: [blank] Duration of residence therein: [blank]
2. FULL NAME: John B. Mc Kenny
(a) Residence No. 1505 11th Street, N.W.
Length of residence in D. of C.: 62 years
PERSONAL AND STATISTICAL PARTICULARS
3. SEX: Male
4. COLOR OR RACE: White
5. Single, married, widowed or divorced(write the word): Widowed
5a. If married, widowed or divorced Husband of (or) Wife of: Sophia Mc Kenny
6. DATE OF BIRTH: (month, day and year) [blank]
7. AGE (years): 92
8. OCCUPATION OF DECEASED:
(a) Trade, profession, or particular kind of work: None
(b) General nature of Industry, business, or establishment in which employed (or employer) [blank]
(c) Name of employer [blank]
9. BIRTHPLACE(City or Town) [blank]
(State or Country) Ireland
PARENTS
10. NAME OF FATHER (in full): Frank Mc Kenny
11. BIRTHPLACE OF FATHER (City or Town) [blank]
(State or Country) Ireland
12. MAIDEN NAME OF MOTHER: Ann Barrett
13. BIRTHPLACE OF MOTHER (City or Town) [blank]
(State or Country) Ireland
14. Above information furnished by: Mary A. McKenny
(Address) 1505 11th St. N.W.
15. Relation of informant to decedent: Daughter
MEDICAL CERTIFICATE OF DEATH
16. DATE OF DEATH: (month, day and year) Jan. 6, 1922
17. I HEREBY CERTIFY That I attended deceased from Dec. 27, 1921 to Jany 6, 1922 that I last saw him alive on Jany 2, 1922 and that death occurred, on the date stated above at 8 a.m.
The CAUSE OF DEATH was as follows:
Cerebral Hemorrage
Duration: 1 day
CONTRIBUTORY (secondary): Asthenia
Duration: 11 days
18. Where was disease contracted if not at place of death: [blank]
Did an operation precede death?: [blank]
Was there an autopsy? [blank]
What laboratory test confirmed diagnosis? [blank]
Signed: Frederick O. Roman, M.D.
(Address) 1918-17 St. N.W.
(City or Town) [blank]
(State or Country) Ireland
19. PLACE OF BURIAL, CREMATION, OR REMOVAL:
Mt. Olivet Cemetery | Date: 1-9-1922
20: UNDERTAKER
Address: Frank Geiers Sons, Co., 1113 7 St. |
