This is the death record for Eleazar Fisher.
It reads:
"ONLY WITH BLACK, UNFADING INK - THIS IS A PERMANENT RECORD" [on left edge vertical]
OF
CERTIFICATE AND RECORD OF DEATH
THIS IS A PERMANENT RECORD" [on left edge vertical]
OF
1. FULL NAME Eleeze Fisher
2. (a) Sex Male (b) Color white (c) Single widowed
2. (a) Sex Male (b) Color white (c) Single widowed
Married
Widowed
Divorced
(WRITE IN)
3. (a) BIRTHPLACE Vermont (b) DaTE OF BIRTH 1810 80- 26
5. DIED ON THE 16 DAY OF June 1913 AT ABOUT 8 A.M.4. age 102 years 6 months 20 DaYS HOURS
6. LAST OCCUPATION (a) (b)
(Trade or Kind of Work) (Industry or Business)
I HEREBY CERTIFY That I Attended Deceased from June 6 1913 to June 16 1913 That I Last Saw Him Alive On The 16 Day of June 1913. That Death Occurred On Date Stated Above At About At About 8 o'Clock A.M. And That To The Best of My Knowledge And Belief THE Cause of his Death Was As HereUnder Written.
(IF UNDER ONE YEAR OLD, STATE HOW PED)
(a) Cause Of Death Senile Dibility (Duration in Years
Months, Days or Hours)
(b) Contributory (Secondary) shock from fall & fractured hip.
WITNESS MY HAND This 20 Day of June 1913
(Signature) Willard Thompson M.D.
Address Sandwich
Rec # 4P [?] Ills
[Vertical]
REPORT OF DEATH
of
DEPARTMENT OF HEALTH
FILED AUGUST 29 1913
Registered By The
S.M. Henderson
COUNTY CLERK
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