Wagers

CERTIFICATE AND RECORD OF DEATH OF

1. Full Name: Joseph Bloemer
2. (a) Sex: Male (b) Color: White (c) Single Married Widowed Divorced: Married
3. (a) Birthplace: Germany (b) Date of Birth:
4. Age 78 Years - Month - Days __ Hours (If less than One Day old)
5. Died on the 8 Day of Feb 1912 at about 5 AM
6. Last Occupation: Farmer (Profession, Trade or Kind of Industry or Business)
7. { From Year __ To Year __ Previous Occupation (if any) __ From __ To __
8. Place of Death: Effingham (Township, Village or City) County of Effingham ** Second Column ** Registered No. __ Effingham County
9. How long in State: 40 Years
10. How long in U.S. if Foreign born __
11. { (a) Name of Father __ (b) Birthplace of Father __
12. { (a) Maiden Name of Mother __ (b) Birthplace of Mother __ The foregoing stated personal particulars are true to the best of my knowledge and belief
13. Informant __ Address __ ** Only one column now **
14. Place of Burial St. anthonys cem