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DEATH CERTIFICATE STATE OF OHIO 1. PLACE OF DEATH: |
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PERSONAL AND STATISTICAL PARTICULARS | MEDICAL CERTIFICATE OF DEATH | ||
3. SEX: Female |
4. COLOR OR RACE: White |
5. Single, Married, Widowed or Divorced Married |
16. DATE OF DEATH: Oct. 19, 1918 |
3a. If married, widowed or divorced. Wife of: John W. Cast |
17. I HEREBY CERTIFY, That I attended deceased from ____
and that death occured on the date stated above, at 11:18 __m. The CAUSE F DEATH was as follows: Broncho Pneumonia duration: 4 ds. CONTRIBUTORY: Influenza duration: 3 ds. Was there an autopsy? No (Signed) H. A._______, M. D. Oct. 17, 1918 (Address) Greenville. |
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6. DATE OF BIRTH: 1863 - 15th Nov? | |||
7. AGE: 54 yrs. |
Months: 11 |
Days: 4 |
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8. OCCUPATION OF DECEASED: Housewife |
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9. BIRTHPLACE: Cincinnati | |||
PARENTS: 10: NAME OF FATHER: John L. Deible 11: BIRTHPLACE OF FATHER: Germany 12: MAIDEN NAME OF MOTHER: Mary E. Baldwin 13: BIRTHPLACE OF MOTHER: Cinti, OHIO |
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14. Informant: John W. Cast |
19. PLACE OF BURIAL, CREMATION OR REMOVAL: Blanchester, Ohio |
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15. Filed: Oct., 1918 C. E. W____m, Registrar |
20. UNDERTAKER License No._____ H. P. Stokes ____l, Greenville, O. |
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(Submitted by Lori Chaffin) |
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