- Registered Number: 14840
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- 1. Place of Death: County of Cook, Registration District No. 3104
- City: Chicago, Street No. Ward: 16
Street and No. 1229 W. 49th Pl.
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- 2. Full Name: Michael Pajewski
- 2a. Residence: 1229 W. 49th Pl.. Chicago, Illinois
- Length of Residence in city or town where death occurred 35 years
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- 3. Sex: Male, 4. Color: White, 5. Marriage Status: Married
- 5a. Name of husband/wife: Helen Pajewski
- 6. Date of Birth: September 12, 1854
- 7. Age: 68 Years 8 Months 2 Days
- 8a. Trade, profession, or particular kind of work: Carpenter
- 8b. General nature of industry or business, or establishment in which employed (or employer):
- 8c. Name of employer:
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- 9. Birthplace: Germany
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- 10. Name of Father: Paul Page
- 11. Birthplace of Father: Germany
- 12. Maiden Name of Mother: Don't Know
- 13. Birthplace of Mother: Germany
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- 14. Informant: Helen Pajewski
- Address: 1229 W. 49th Pl.
- 15. Filed: 5-16-23
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- Medical Certificate of Death:
- 16. Date of Death: May 14, 1923
- 17. I hereby certify, that I attended deceased from February 10, 1923 to May 14, 1923, that I last saw him alive on May 5th, 1923 and that death occurred, on the date stated above, at 9 P. M. The cause of death was as follows:
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- Chronic Myocarditits 6 months
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- Contributory (Secondary):
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- Did an operation precede death: No
- Was there an autopsy: No
- What test confirmed diagnosis: classical symptoms
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- 18. Place of Burial: St. Marys
- 19. Date of Burial: May 17, 1923
- 20. Undertaker: Wm. G. Scharf Address: 5021 Ashland
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