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State of New York
Department of Health of The City of New York
Bureau of Records
Certificate of Death - Registered No. 5390
1 Place of Death, Borough of Queens, 45 Jackson Ave.
Character of premises whether tenement, private, hotel, hospital or other place etc. - Tenement
2 FULL NAME - Amy Mulcahy
3 Sex - Female, 4 Color or Race - White, 5 Single, Married, Widowed, or Divorced - Married
6 Date of birth - November 3, 1871.
7 Age - 54 yrs mos days.
8 Occupation - A. Trade, profession, or particular kind of work, - Housewife
B General nature of Industry, Business or establishment in which employed (or Employer) - .
9 Birthplace (State or Country) - Ireland
9 (A) How long in U.S. (if of foreign birth) - 36 Years. 9 (B) How long resident in city of New York - 36 Years.
10 Name of Father - William Dwyer.
11 Birthplace of Father - Ireland.
12 Maiden name of Mother - Mary Cavanagh.
13 Birthplace of Mother - Ireland.
14 Special INFORMATION required in death in hospitals and institutions and in deaths of non-residents and recent residents. Former or usual residence - 45 Jackson Ave.
15 Date of Death - Nov 10, 1925.
16 I hereby certify that the foregoing particulars (Nos. 1-14 inclusive) are correct as near as the same can be ascertained, and I further certify that I attended the deceased from Oct 28 1925 to Nov 10 1925, that I last saw her alive on the 10 day of Nov 1925, that the death occurred on the date stated above at 10 p.m., and that the chief and determining cause of death was Acute Lobar Pneumonia duration yrs. mos. 13 days. Contributory (Secondary) - .
Witness my hand this day of 192 . Signature P J Mc Keown??, Address 300 Fifth Ave.
17 Place of Burial - Calvary Cemetery. Date of Burial Nov 13th, 1925.
18 Undertaker - Edward J ?? Ward Licence 887, Address - 111 East Ave, L. I. City NY
I hereby certify that I have been employed as undertaker by Thomas Mulcahy the husband of deceased. This statement is made to obtain a permit for burial or cremation of the remains of deceased Amy Mulcahy. Signature - Edward J ??Ward |
