| PROVINCE OF MANITOBA |
| OFFICIAL REGISTRATION OF DEATH |
|
|
| 1 PLACE OF DEATH |
Winnipeg, Winnipeg General Hospital |
| 2 NAME OF DECEASED |
Galdzinski Teresia, 586 Selkirk Ave |
| 3 If married or widowed give full maiden name |
Chlod Theresa |
| 4 Sex |
Female |
| 5 Nationality |
Polish |
| 6 Marital Status |
Widow |
| 7 Place of Birth |
Sieniakowa, Csortkow, Poland |
| 8 Date of Birth |
[unknown month, day] 1859 |
| 9 Age of deceased |
75 |
| 10 Occupation or former occupation of deceased |
At homoe |
| 11 Length of Residence: at place of death |
3 days |
| in Province |
24 years |
| in Canada |
30 years |
| 12 Full name of father |
Unknown Chlod |
| 13 Birthplace of father |
Sieniakowa, Csortkow, Poland |
| 14 Maiden name of mother |
Unknown |
| 15 Birthplace of mother |
Sieniakowa, Csortkow, Poland |
| 16 Your relationship to deceased |
Son |
| 17 Were you in the room at the time of death |
No |
| 18 Signature of informant |
Jos Galdzinski, 402 Manitoba Ave. |
| MEDICAL CERTIFICATE OF DEATH |
| 19 Date of Death |
1934-03-09 3:00 am |
| 20 I hereby certify that I attended deceased death |
[illegible] 9 March 34 |
| CAUSE OF DEATH |
| Under subsection 32(12) of The Vital Statistics Act the cause of death is not disclosed |
| 22 Date of burial or removal |
March 12, 1934, St. Mary’s Cemetery |
| 23 Burial permit was issued by |
M Peterson, Winnipeg |
| 24 Signature of Underkater |
John Zawidoski, 561 Selkirk Ave |
| 25 Registered number |
1370 14 March 34 |
