Reg. Dist. No. 901
Primary Reg. Dist. No. 5369 |
OHIO
DEPARTMENT OF HEALTH
DIVISION OF VITAL STATISTICS
CERTIFICATE OF DEATH |
State File No. 25659
Registrar's No. 5 |
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1. PLACE OF DEATH:
a. COUNTY: Montgomery |
2. USUAL
RESIDENCE:
a. STATE: Ohio b. COUNTY:
Clinton |
b. CITY
or VILLAGE:
Butler Township |
c. LENGTH
OF STAY
8 yrs. |
c. CITY OR VILLAGE:
Blanchester, O |
d. FULL NAME OF HOSPITAL
OR INSTITUTION:
Home |
d. STREET OR RURAL
ADDRESS: (Blank) |
3. NAME OF DECEASED
Laura - Hudson |
4. DATE OF DEATH:
April 29, 1949 |
|
5. SEX: F |
6. COLOR OR RACE:
W |
7. MARRIED, NEVER
MARRIED, WIDOWED, DIVORCED:
Single |
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8.
DATE OF BIRTH:
Mar. 9, 1869 |
9. AGE (last
birthday):
80 yrs. 1 mo. 20 ds. |
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10a. USUAL OCCUPATION:
Domestic
10b. KIND OF BUSINESS OR INDUSTRY:
(blank) |
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11. BIRTHPLACE:
Clinton Co., Ohio |
12. CITIZEN OF WHAT
COUNTRY? U.S. |
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13. FATHER'S NAME:
George Hudson |
14. Mother's Maiden Name:
Rachel Hammer |
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15. WAS DECEASED EVER IN
U.S. ARMED FORCES? X |
16. SOCIAL SECURITY NO. X |
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17. INFORMANT'S
SIGNATURE: Irma Brown, Box 258 Route 1,
Irma Brown, Dayton 5, Ohio |
CAUSE OF DEATH:
MEDICAL CERTIFICATION:
1. DISEASE OR CONDITION DIRECTLY LEADING
TO DEATH:
(a) Cerebral Hemorrhage
ANTECEDENT CAUSES:
Morbid conditions, if any, giving DUE TO
(b) Hypertension
Interval between onset and death:
7 am 28th April to 8:35 a. 29 ap. |
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20. Autopsy? No |
23a. SIGNATURE: R.
A. Welty, M.D. 23b. ADDRESS:
295 Perry, Vandalia, Ohio
23c. DATE SIGNED: 30 April 49 |
24a. BURIAL, CREMATION,
REMOVE: Burial
24b. DATE: May 2, 1949
24c. NAME OF CEMETERY OR CREMATORY:
Blanchester I.O.O.F. Cem.
24d. LOCATION: Blanchester, Ohio |
|
NAME OF EMBALMER:
J. F. Keefe |
DATE REC'D BY LOCAL REG.
4/30
REGISTRAR'S SIGNATURE: R. A. Rader
25. FUNERAL DIRECTOR'S SIGNATURE:
C. B. Eichelbuger
LIC. NO. 39 |
