.GEURKINK .
| Harvey
E. Geurkink
April 2, 1974 contributed by Ron Renquin DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH ORIGINAL CERTIFICATE OF DEATH STATE FILING DATE APR - 8 1974 STATE DEATH NO. 74 009021 483 LOCAL FILE NUMBER DECEASED--NAME First Middle Last 1. Harvey E. Geurkink SEX 2. male DATE OF DEATH Month Day Year 3. April 2, 1974 RACE--White, Negro, American Indian, Etc. 4. white (Specify) Age Last Birthday Years 5a. 54 Under One Year Months Days 5b. Under One Day Hours Minutes 5c. DATE Month Day Year OF BIRTH 6. Oct. 10, 1919 COUNTY OF DEATH 7a. Milwaukee NAME OF CITY, VILLAGE (If Neither, Name Township) (Location of Death) 7b. Wauwatosa Inside City or Village Limits 7c. X Yes No HOSPITAL OR OTHER INSTITUTION--NAME (If Not in Either Give Street and Number or Location) 7d. Milwaukee County Hospital STATE OF BIRTH (If Not in U.S.A., Name Country) 8. Wis. CITIZEN of What Country 9. USA X Married Never Married 10. Widowed Divorced SURVIVING SPOUSE (If Wife, Give Maiden Name) 11. Magdalen Ryan SOCIAL SECURITY NO. 12. 395-12-1756 USUAL OCCUPATION Give Kind of Work During Most of Working Life Even if Retired 13a. Machinist KIND OF BUSINESS OR INDUSTRY 13b. Harly* Davison* Mfg. Co. RESIDENCE: STATE 14a. Wis. COUNTY 14b. Milwaukee NAME OF CITY, VILLAGE (If Neither, Name Township) 14c. Milwaukee Inside City or Village Limits 14d. X Yes No MAILING ADDRESS (Home Address at Time of Death) 14e. 5923 W. Blumond FATHER--NAME First Middle Last 15. Ray* Geurkink MOTHER--MAIDEN NAME First Middle Last 16. Marjorie Johnson INFORMANT--NAME 17a. Magdalen Geurkink MAILING ADDRESS Street or R.F.D. No. City or Village State Zip 17b. 5923 W. Blumond Milwaukee,Wis. WAS DECEASED EVER IN U.S. ARMED FORCES? (If Yes, Give War or Dates of Service) 17c. X Yes No Unknown W W2 18. PART I DEATH WAS CAUSED BY - Enter Only One Cause Per Line For (A), (B), and (C) Conditions, If Any, Which Gave Rise to Immediate Cause (A) Stating the Under- Lying Cause Last. Duration A. Immediate Cause: CORONARY ARTERY INSUFFICIENCY, ACUTE. Due to, or as a B. Consequence of: ARTERIOSCLEROTIC HEART DISEASE. Due to, or as a C. Consequence of: PART II OTHER SIGNIFICANT CONDITIONS: Conditions Contributing to Death but not Related to Cause Given in Part I (A) AUTOPSY (Specify) 19a. Yes X No WERE AUTOPSY FINDINGS CONSIDERED IN DETERMINING CAUSE OF DEATH? 19b. Yes No ACCIDENT SUICIDE 20a. HOMICIDE DATE OF Month Day Year INJURY 20b. Hour M. 20c. HOW INJURY OCCURRED (Enter Nature of Injury in Part I or Part II, Item 18) 20d. INJURY AT WORK Yes No 20e. PLACE OF INJURY (Home, Farm, Street, Factory, Etc. 20f. (Specify) LOCATION Street or R.F.D. No. City or Village State Zip 20g. CERTIFICATION--Month Day Year PHYSICIAN I Attended The Deceased From 21a. To Month Day Year 21b. AND LAST SAW HIM/HER ALIVE ON Month Day Year 21c. DID YOU VIEW THE BODY AFTER DEATH 21d. Yes No DEATH OCCURRED At The Place, on The (Hour) Date, and, To The Best of My Knowledge, Due To The Cause(s) Stated. 21e. M. CERTIFICATION--MEDICAL EXAMINER OR CORONER: On The Basis of The Examination of The Body and/or The Investigation, In My Opinion, Death Occurred on The Date and Due To The Cause(s) Stated. HOUR OF DEATH 22a. 3:28 P. M. THE DECEDENT WAS PRONOUNCED DEAD Month Day Year Hour 22b. 4 - 2 - 74 3:28 P. M. CERTIFIER--NAME (Type or Print) 23a. C. P. ERWIN,M.D. SIGNATURE--CERTIFIER Medical Exam. Title 23b. CPErwin M.D. MEDICAL EXAMINER DATE SIGNED Month Day Year 23c. 4 - 5 - 74. MAILING ADDRESS--CERTIFIER Street or R.F.D. No. City or Village State Zip 23d. SAFETY BUILDING,ROOM 232, MILWAUKEE, WISCONSIN 53233 X BURIAL CREMATION 24a. REMOVAL CEMETERY OR CREMATORY--NAME 24b. Veterans Cemetery LOCATION City State 24c. Wood,Wis. BURIAL--DATE Month Day Year 24d. April 5, 1974 FUNERAL HOME--NAME AND ADDRESS Street or R.F.D. No. City or Village State Zip 25a. Ermenc* F H 5325 W. Greenfield Ave. Milwaukee,Wis. 53214 FUNERAL DIRECTOR--SIGNATURE 25b. J Wayne McLeod REGISTRAR--SIGNATURE 26a. Richard O. Mossey MD PTHC DATE RECEIVED By Local Registrar Month Day Year 26b. APR 5 1974 * The entries have been transcribed exactly from the original so that any misspelling or errors of a person's name, place name, date, or any other entry is intentional. |