Death Certificate of Mary A. Hickman

Transcription – Death Certificate for Mary Hickman of Montgomery, Ohio

Transcription – Death  Certificate for Mary Hickman of Montgomery, Ohio.

Death Certificate of Mary A. Hickman
Death Certificate of Mary A. Hickman

STATE  OF OHIO
BUREAU OF VITAL STATISTICS
CERTIFICATE OF DEATH

___________________
1  PLACE OF DEATH
County   Montgomery     Registration District  No.  902     File No. _________________
Township  Clay     Primary Registration District  No. 5370     Registered No.  33055
or Village  _________________________     No.  ____, ________________St., ______ Ward
(If death in a hospital or institution, give its NAME instead of street and number)
or City of  __________________________
2  FULL NAME  Mary Hickman
(a)  Residence.     No.  ______________________St., ______ Ward. _________________
(Usual place of abode.)                              (If nonresident give city or town and State)
How long in U.S. if of foreign birth?            yrs.            mos.            ds.

——  PERSONAL AND STATISTICAL PARTICULARS ——

____________________________________________________________________________
3  SEX      |      4  COLOR OR RACE      | 5  Single, Married, Widowed or Divorced (write the word)
Female |          White                            |     Widowed
____________________________________________________________________________
5a   If married, widowed or divorced, HUSBAND of (or) WIFE of  John Hickman
____________________________________________________________________________
6  DATE  OF BIRTH  (month, day, and year)  Dec-30-1839
____________________________________________________________________________
7  AGE            Years  83    | Months  X    | Days    X    | If LESS than 1 day ___ hrs. or ___ min.
___________________________________________________________________________________
8  OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work  Housewife        (Handwritten notation: 74a)
(b) General nature of Industry, business, or establishment in which employed (or employer)  X
(c) Name of Employer  X
___________________________________________________________________________________
9  BIRTHPLACE (city or town)  Stringtown, Ohiio
(State or country)  Montgomery Co
___________________________________________________________________________________
|  10  NAME OF  FATHER  ­ Isaac Burkett
|  11  BIRTHPLACE OF FATHER (city or town)              (State or country)  North Carolina  
|  12  MAIDEN NAME OF MOTHER  Katharina Burkett
|  13  BIRTHPLACE OF MOTHER (city or town)              (State or country)  Not Known
___________________________________________________________________________________
14  Informant    Joseph Stick
(Address)     RR #2 Brookville O
___________________________________________________________________________________
15  Filed   Dec. 31, 1922        Jos E Smith   REGISTRAR
___________________________________________________________________________________

——  MEDICAL CERTIFICATE OF DEATH ——

___________________________________________________________________________________
16  DATE OF DEATH  (month, day and year)  12-30-1922
___________________________________________________________________________________
17                     I HEREBY CERTIFY, That I attended deceased from July, 1922, to Dec. 30, 1922, that I last saw her alive on Dec. 30, 1922, and that death occurred, on the date, stated above, at 2 P.m.
The CAUSE OF DEATH* was as follows:
Cerebral hemorrhage (second attack. 1st in July, 1922)
_______________    _______________ (duration)  ____ yrs.  ­­­­____ mos.  ____ ds.
CONTRIBUTORY (Secondary) ____________________________________________________________
_______________    _______________ (duration)  ____ yrs.  ­­­­____ mos.  ____ ds.
18  Where was disease contracted if not at place of death? _______________    ______________
Did an operation precede death? _______________    ___________  Date of
Was there an autopsy? _______________    ______________
What test confirmed diagnosis? _______________    ______________
(Signed) __________________J. H. Pumphrey_________________, M. D.
___12-31-,1922__  (Address)      Clayton, O.

*State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL OR HOMICIDAL.   (See reverse side for additional space.)
___________________________________________________________________________________
19  PLACE OF BURIAL, CREMATION OR REMOVAL               |              DATE OF BURIAL
Shilo Cemetery                        |         Shipped to Granville, Ill. Dec 31st 1922
___________________________________________________________________________________
20  UNDERTAKER, License No.                |    ADDRESS
S. A. Dunkel                                              |    Brookville, Ohio
___________________________________________________________________________________

(Form text in left margin):
(Torn or cut off)… of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back of certificate.

___________________

The image above links directly to the original document. You can access sources, data, images and documents for these and other individuals, by clicking on the name link, or searching the Blythe Genealogy database site using the surname search link and the ‘All Media‘ search link in the left sidebar.

It is recommended to search using both methods as the results can differ greatly due to a glitch in the software that doesn’t connect all images from the bio.

All data for this and numerous others on this site is available for free access and download.

Spread the love...
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  

Leave a Comment