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Grace (van Wijk, Boezel) Decker Death

Note: Hand-written, typed or stamped text is enclosed in brackets ({ }) below. If an underlined entry field was left blank, it is indicated as {(no entry)}. Filed: {Aug 21 1915} {21637} Registered No.: {21637} Certificate of Death - Physician's Form Undertaker's Certificate and Record of Death of 1. Full Name: {Grace Decker} 2. (a) Sex {F} (b) Color {W} (c) Single, Married, Widowed or Divorced: {Married} 3. (a) Birthplace: {Holland} (b) Date of Birth: {March 29th 1857} 4. Age: {58} years {4} Months {22} Days {(no entry)} Hours 5. Died on the {20} Day of {Aug} 191 {5} at about {6 A} M 6. Last occupation - (a) {Housewife} (b) Industry or Business: {(no entry)} (c) From the year {(no entry)} To the year {(no entry)} 7. Previous occupation: {(no entry)} 8. (a) Place of Death: {3517 S Francisco Ave} (b) How long at place of death: {8 years} 9. (a) Usual Residence: {(same)} (b) Ward: {5 - ch. 10} [apparently change of ward to 10] 10. How long resident in city? {34 Years} 11. How long in state? {34 Years} 12. How long in U. S. if foreign born? {46 years} 13. (a) Name of Father: {Burt Van Wyke} (b) Birthplace of Father: {Holland} 14. (a) Maiden Name of Mother: {Unknown} (b) Birthplace of Mother: {Holland} ______________________________________ 15. The foregoing stated personal particulars are true to the best of my knowledge and belief. Informant: {George Decker} Address: {3517 S Francisco Ave.} ______________________________________ 16. Place of Burial: {Forest Home} Date of Burial: {Aug 22nd 1915} Hour {1 P.} M. 17. Undertaker: {John T. Kelly} Address: {2616 W 38 St} License No.: {270} ______________________________________ Physician's Certificate of Cause of Death I hereby certify that I attended deceased from {Aug 1}, 191 {5} to {Aug 20}, 191 {5} that I last saw {her} alive on the {14} day of {Aug} 191 {5} that {she} died on the day and at about the time stated above, and that to the best of my knowledge and belief the cause of {her} death was as hereunder written. (a) Cause of death: {Cirrhosis of the Liver} Duration in years, months, days or hours: {5 ?weeks?[could be months]} (b) Contributory (Secondary): {(no entry)} Witness my hand this {15th} day of {Aug} 191 {5} (Signature) {?Robt Van Dellen?} M.D. Address: {7100 Emerald Ave} Telephone: {St??? 72??(bleached out)} {Alcoholic, 8/24}