1. PLACE OF DEATH: County of Mason Havana Primary Dist. No. 3474 Street and Number, No. 521 Broadway St.
2. FULL NAME: Fannie L. DUBUIS Residence: No.___ Proctor Home Peoria, Illinois
3. SEX: female 4. COLOR OR RACE: white 5. Single, Married Widowed: widow 5a. If married widowed or divorced Husband or Wife of: Oscar F. DUBUIS 6. DATE OF BIRTH: Aug. 30, 1852 7. AGE: 82 years 1 Month 10 Days 8. Trade profession or particular kind of work done, as spinner, sawyer, bookkeeper, etc.: retired 9. Industry or busines in which the work was done: none 10. Date deceased last worked: blank 11. Total time spent in occupation: blank 12. BIRTHPLACE: Sacremento, Calif. FATHER: 13. NAME: Mr. GIRARD 14. BIRTHPLACE: do not know MOTHER: 15. MAIDEN NAME: do not know 16. BIRTHPLACE: do not know 17. INFORMANT: Kathryn MOWDER 18. PLACE OF BURIAL: Springdale cemetery, Peoria, Ill., Peoria County, Ill. 19. DATE: Oct 11, 1934 20. UNDERTAKER: Js. W. Winzler, Winzler Undertaking Co., Peoria, Ill 21. DATE OF DEATH: Oct. 9, 1934 22. I HEREBY CERTIFY That I attended deceased from: Oct. 7, 1934 to Oct. 9, 1934 I last saw her alive on: Oct. 9, 1934; death is said to have occurred on the date stated above, at: 7:30 A.M. *The principal cause of death and related causes of importance were as follows: acute bronchitis. Date of Onset: Oct. 6, 1934. Other contributory causes of importance: arterioscleroses. Date of Onset: unknown. 23. Was an operation performed? __Date of?__ For what disease or injury?__ Was there an autopsy?__ What test confirmed diagnosis?__ 24. If communicable disease where contracted?__. Was disease in any way related to occupation of the deceased? no. Signed: C.H. STUBENRAUCH, M.D. Havana, Ill. Date: Oct. 9, 1934 telephone 3 25. Filed Oct 9, 1934 Paul R. KRAMER, Registrar, P.O. Address Havana, Ill. Stamped: Filed NOV 10 1934 Earl B. COATS Clerk of the County Court (SOURCE>State of Illinois, Department of Health-Division of Vital Satistics-STANDARD CERTIFICATE OF DEATH-Registered No. 46 COUNTY CLERK'S RECORD 5M-580)
*Note: The marriage license of Frances and Oscar says she was born in Greenpoint, Kings, New York
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