5b. Mos.         Days
       UNDER 1 DAY

  5c. Hours        Mins.
  DATE OF BIRTH
         July  13,  1923
  6.    Month    Day    Year
  COUNTY OF DEATH
  7a.    Milwaukee
  INSIDE CITY OR
  VILLAGE LIMITS
     X  Yes     No
   7b.
  CITY, VILLAGE OR TOWNSHIP OF DEATH
  7c.    Milwaukee
  HOSPITAL OR OTHER INSTITUTION--NAME
  X  Hospital     Nursing Home     Other Instit
  (If none of these, give street and number)
  7d.    Veterans Administration Medical Center
  IF HOSP OR INST
                DOA
                OP/Emer Rm
  7e.     X  Inpatient
  STATE OF BIRTH (If Not in
  U.S.A., name country)
  8.    Colorado
  CITIZEN OF WHAT COUNTRY
  9.    USA
  MARITAL STATUS
        X  1. Married           4. Never Married
             2. Separated        5. Widowed
  10.      3. Divorced
  SURVIVING SPOUSE (If wife, give maiden name)
  11.    Joan(Catencamp)    Moore
  WAS DECEDENT EVER IN U.S.
  ARMED FORCES?
  12. X Yes              No    WW#2
  SOCIAL SECURITY NUMBER
  13.    524-12-5884
  USUAL OCCUPATION (Give kind of work done during most of working
  life, even if retired)
  14a.    Painter
  KIND OF BUSINESS OR INDUSTRY
  14b.    Construction Company
  RESIDENCE-STATE
  15a.    Wisconsin
  COUNTY
  15b.    Milwaukee
  CITY, VILLAGE OR TOWNSHIP OF RESIDENCE
  15c.    Milwaukee
  INSIDE CITY OR
  VILLAGE LIMITS
     X  Yes     No
  15d.
  STREET AND NUMBER
  15e.    2017A  N. 40 St.
  FATHER-NAME    First    Middle    Last
  16.                          James                Moore
  MOTHER-MAIDEN NAME    First    Middle    Last
  17.                                          Lauretta             Christner
  INFORMANT-NAME (Type or Print)
  18a.    VA Hospital Records
  MAILING ADDRESS    Street or R.F.D. No.    City or Village    State    Zip
  18b.    VA Medical Center, 5000 W. National Ave., Wood, WI 53193
         X  1. Burial               4. Removal
              2. Cremation        5. Other
  19a.    3. Entombment
  CEMETERY OR CREMATORY-NAME
  19b.    Wood National Cemetery
  LOCATION    City or Village    State
  19c.    Milwaukee    Wisconsin
  FUNERAL SERVICE LICENSEE Or Person Acting As Such
  Signature
  20a.    (unreadable)
  NAME OF FACILITY
  20b.    Becker-Ritter
  ADDRESS OF FACILITY    Street or R.F.D. No.    City or Village    State    Zip
  20c.    5330 W. Lisbon Ave., Milwaukee, WI 53210
       To be Completed by
  CERTIFYING PHYSICIAN
                  Only
  21a. To the best of my knowledge, death occurred at the time, date and place
  and due to the cause(s) stated.
  Signature and Title    DHerdeman MD
  DATE SIGNED
  October - 18 - 82
  21b.    Month    Day    Year
  HOUR OF DEATH
  21c.    8:30 AM                        M
  NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print)
  21d.
     To be Completed by
  MEDICAL EXAMINER
     or CORONER Only
  22a. On the basis of examination and/or investigation, in my opinion death
  occurred at the time, date and place and due to the cause(s) stated.
  Signature and Title
  DATE SIGNED

  22b.    Month    Day    Year
  HOUR OF DEATH
  22c.                                         M
  PRONOUNCED DEAD

  22d.    Month    Day    Year
  PRONOUNCED DEAD (Hour)
  22e.                                         M
  NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, MEDICAL EXAMINER OR
  CORONER) (Type or Print)
  23.    D. Herdeman, M.D., VA Medical Center, 5000 W. National Ave., Wood, WI
           53193
  REGISTRAR
  24a. Signature    (unreadable)
  DATE RECEIVED BY REGISTRAR
             OCT 21 1982
  24b.    Month    Day    Year
        25.
      PART
          I
  Conditions
      if any
  which gave
      rise to
  Immediate
      Cause
  stating the
  underlying
   cause last
  IMMEDIATE CAUSE [ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c).]
                                                                                  Interval between onset and death
  (a)    Respiratory Arrest                                                                            minutes
       DUE TO, OR AS A CONSEQUENCE OF:      Interval between onset and death
  (b)    Prostrate Cancer                                                                                 1 year
       DUE TO, OR AS A CONSEQUENCE OF:      Interval between onset and death
  (c)
      PART
         II
  OTHER SIGNIFICANT CONDITIONS-Conditions contributing to death but not
  related to cause given in PART I (a)

  AUTOPSY
  26.      Yes  X  No
  WAS MEDICAL EXAMINER OR
  CORONER NOTIFIED?
  27.          YesXXNo
      1. Accident        4. Undet.
      2. Suicide          5. Pend. Invest
      3. Homicide
  28a.
  DATE OF INJURY

  28b.     Month    Day    Year
  HOUR OF INJURY
                                    M
  28c.
  DESCRIBE HOW INJURY OCCURRED

  28d.
  INJURY AT WORK
                 Yes     No
  28e.
  PLACE OF INJURY-At home, farm, street, factory, office building, etc.
  (Specify)
  28f.
  LOCATION    Street or R.F.D. No.    City or Village    State

  28g.
* 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