Certificate of Death - Physician's Form: Undertaker's Certificate and Record of Death of Anna Sarire Weber

              CERTIFICATE OF DEATH-PHYSICIAN'S FORM
        UNDERTAKER'S   REGISTERED No.________
           CERTIFICATE AND RECORD OF DEATH  DEPARTMENT OF HEALTH
         OF    CITY OF CHICAGO
1. FULL NAME Anna Sarire Weber__________________________________10.  HOW LONG RESIDENT IN CITY Life_______
2. (a) SEX F  (b) COLOR W (c) SINGLE MARRIED WIDOWED DIVORCED Single 11. HOW LONG IN STATE Same________
3. (a) BIRTHPLACE Chicago (b)DATE OF BIRTH January 31, 1912_______12. HOW LONG IN U.S. IF FOREIGN BORN
4. AGE 1__  YEARS 11__ MONTHS 12__ DAYS  ____ HOURS        13.  (a) NAME OF FATHER Michael Weber________
5. DIED ON THE 12_  DAY OF January_  1914 AT ABOUT 8 a.m.   (b) BIRTHPLACE OF FATHER Chicago
6. LAST OCCUPATION (a) __________  ______ (b) ___________________ 14.  (a) MAIDEN NAME OF MOTHER Carrie Becker 
    FROM THE YEAR (c) ______________ TO THE YEAR ______________   (b) BIRTHPLACE OF MOTHER Chicago______
7. FORMER OCCUPATION (a) _______________ (b) __________________ The foregoing stated personal particulars are true to the 
    FROM THE YEAR (c) ______________ TO THE  YEAR______________      best of my knowledge and belief:
8. (a) PLACE OF DEATH Tessvill [sic] HOW LONG AT PLACE OF DEATH one day  15.  INFORMANT Michael Weber 
9. (a) USUAL RESIDENCE Niles Center  ________(b)WARD ____________     ADDRESS      Niles Center__
     PLACE OF BURIAL St. Peters Niles Center 17. UNDERTAKER N P Weimeschkirch_____  License No.
16. DATE OF BURIAL January - 14 - 1914__         ADDRESS        7066 N. Clark St ___ _________
      HOUR 2 PM.          TELEPHONE Evanston 1065
      PHYSICIAN'S CERTIFICATE OF CAUSE OF DEATH
 I HEREBY CERTIFY THAT I ATTENDED DECEASED FROM January 11  1914 TO January 12 1914 THAT I LAST SAW her ALIVE ON THE 11 DAY OF January 1914 THAT she DIED ON THE DAY AND AT ABOUT THE HOUR STATED ABOVE, AND THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE CAUSE OF _____ DEATH WAS AS HEREUNDER WRITTEN.
(IF UNDER ONE YEAR OLD, STATE HOW FED)

(a) CAUSE OF DEATH Burned by falling in hot ashes                                      DURATION*  IN YEARS MONTHS, DAYS OR HOURS ____________(Lower half of body and left arm)_________________
(b) CONTRIBUTORY (SECONDARY) Shock - inhalation of hot gas fumes *Of each Cause according to the Clinical History.
 Witness my hand THIS 14___  (SIGNATURE) A. Louise Klehm__ M.D.
      DAY OF January _________1914  ADDRESS Niles Center, Ill. TELEPHONE 12 R.