Death Record
Illinois
Standard Certificate of Death
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- Registered Number: 29142
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- 1. Place of Death: County of COOK, Registration District
No. 3104
- City: CHICAGO, Street No. 811 WEST 27th St.Ward: 4
- Length of Time in city or town where death occurred: --
- How long in U. S. if of foreign birth: 38 yrs
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- 2. Full Name: MARTHA VANDERKLOOT
- Residence: No. 811 WEST 27th St.
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- 3. Sex: FEMALE, 4. Color: WHITE, 5. Marriage Status: MARRIED
- 5a. Name of husband: ADRIAN
- 6. DATE of BIRTH: MARCH 28, 1859
- 7. Age: 61 Years 6 Months 27 Days
- 8. Trade, profession, or particular kind of work: HOUSEWIFE
- Industry or business in which work was done: --
- Name of employer: AT HOME
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- 9. Birthplace: NETHERLAND
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- 10. Father's Name: ARTHUR TANIS
- 11. Father's Birthplace: NETHERLAND
- 12. Mother's Maiden Name: ALETTA BLAAKE
- 13. Mother's Birthplace: NETHERLAND
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- 14. Informant: ADRIAN VANDERKLOOT
- Address: 811 WEST 27th ST.
- 15. Filed: 10-26-20
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- Medical Certificate of Death:
- 16. Date of Death: OCTOBER 25, 1920
- 17. I hereby certify that I attended deceased from October 13,
1920 to October 25, 1920
- I last saw HER alive on the October 24, 1920 and that death occurred
on the date stated above, at 7 A. M.
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- The cause of death was as follows: UREMIA 28 days
- Contributory: CHRONIC INTERSTITIAL NEPHRITIS
- HYPERTENSION Duration: 5 years
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- 18. Did an operation precede death: NO
- Was there an autopsy: NO
- What test confirmed diagnosis: PHYSICAL AND LABORATORY
- Signed: ALBERT VANDERKLOOT M.D.
- 4242 Milwaukee Av.
- Date: October 26, 1920
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- 19. Place of Burial: OAKWOODS, Location: CHICAGO, County:
COOK, State: ILLINOIS
- 19. Date of Burial: OCT. 28, 1920
- 20. Undertaker: J. ALBERTI Address: 844 W. 63rd
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