Missouri State Board of Health
Bureau of Vital Statistics Certificate of Death
1. Place of Death
County_________________ Registration District No_________________ File No. ________________ Township_______________ Primary Registration District No_________ Registered No.____________ City________St. Louis, Mo_______________________ 2. Full Name_______John Milton McMillin______________________________________________________________________________ Residence, No____2512 N. 10th St.______ __________________________ Ward ________5__________________ Length of residence in the city or town where death occurred________yrs_____mos_______days |
Personal and Statistical Particulars
3. Sex______Male_____ 4. Color or Race____White______ 5. Single, Married, Widowed, Divorced___Widowed_______ 5a. Husband or Wife of___________________________________________ 6. Date of Birth___Dec 16th 1829_________ 7. Age Years___92______Months___10______days___11________ Occupation : 8. Trade, Profession_______Farmer___________________________ Industry or Business___Retired 20 years______________________________ 9. Birthplace_____St Charles Co, Missouri___________________ 10. Father's Name_________John McMillin_____________________________________ 11. Father's Birthplace City or Town _____________ State or Country___Missouri_________ 12. Mothers Maiden Name______Not known______________________________________ 13. Mother's Birthplace City or Town ____________________ State or Country_Missouri__________ 14. Informants Name and Address____John McMillin 2512 N 10th St._________ 15. Filed (registrar)_____Max G. Starkloff______________________ |
Medical Certificate of Death
16. Date of Death____Oct 27th, 1922_____________________ 17. I HEREBY CERTIFY that I attended the deceased from ____Oct 1st, 1922_______to ________Oct 27th, 1922____ I last saw ____him__________alive ___Oct 27th, 1922________Death is said to have occurred on the date stated above at __11:30 PM _________________ The cause of death was as follows: ____________________Bronchial Pneumonia_____________________________ _____________________________________________________ ________________________________________ Contributary (Secondary): _________________________Arterio Sclerosis________________________________ ___________________________________________________ 18. Where was disease contracted?_____________________________________ What test confirmed diagnosis_______________________ Was there an autopsy?________ 19. Place of Burial___St. Mathews__________ Date ____Oct 29, 1922___________ 20. Undertaker_Hy Leidner Undertaker________ Address _____1417 N Market St.____________________________ |
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