peters_rangebooks_v17_lodi_093_p044

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Form V. S. No. 11—5OOM-3-1-O9
PLACE OF DEATH. RETURNED
STATE OF OHIO
BUREAU OF VITAL STATISTICS
CERTIFICATE OF DEATH
County of Athens
Township of Lodi Registration District No. 4115 File No. 6813
or
Village of........... Primary Registration District No. 4115 Registered No. 4
or
City of.............. (No. ............. St., ............ Ward)
(If death occured in a
Hospital or Institution
give its NAME instead
of street and number.)
(If death occurs away from
USUAL RESIDENCE
give facts called for under
"Special Information."
FULL NAME Henry Connett Williams
PERSONAL AND STATISTICAL PARTICULARS
SEX male
COLOR OR
RACE White
DATE OF BIRTH March 19 1820
(Month) (Day) (Year)
AGE
[illegible] years, 11 months, 3 days.
SINGLE, MARRIED,
WIDOWED, OR DIVORCED Married
BIRTHPLACE
(State or Foreign Country) of New Jersey
OCCUPATION farmer
NAME OF FATHER Abriham Williams
BIRTHPLACE OF FATHER
(State or Foreign Country) New Jersey
MAIDEN NAME OF MOTHER Margrett [illegible]
BIRTHPLACE OF MOTHER
(State or Foreign Country) New Jersey
THE ABOVE STATED PERSONAL PARTICULARS ARE
TRUE TO THE BESWT OF MY KNOWLEDGE AND BELIEF
(Informant) L. J. Williams
(Address) Carpenter Ohio
Filed
Feb 23 1913
S.J. [illegible]
Registrar.
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
2 22 1913
(Month) (Day) (Year)
I HEREBY CERTIFY, That I attended deceased from
Feby 18 1913 to Feby 22 1913
and I last saw him alive on Feby 18 1913
and that death occurred, on the date stated above, at 9
PM. The CAUSE OF DEATH was as follows:
Pneumonia
92B (Duration) 5 Days
Contributory......
(Duration).......
(Signed)......... C L Orr M.D.
Feby 23 1913 (Address) Pratts Fork O.
SPECIAL INFORMATION only for Hospitals, Institutions, Tran-
sients, or Recent Residents.
Former or
Usual Residence.......
How long at
Place of Death?......... Days
Where was disease contracted,
If not at place of death?...........
PLACE OF BURIAL or REMOVAL
Pratts Fork
DATE OF BURIAL
Feb 25 1913
UNDERTAKER ADDRESS
C. S. [illegible], Athens O
I hereby certify that the above is a photostatic copy of the original
certificate of death of Henry Connett Williams
which is registered and preserved in the Vital Statistics Division of the
Ohio Department of Health. 000044
Witness my hand and seal as Chief of the Vital Statistics Division
this the 9th day of October 1941
No. 17412
W H Veigel
Chief, Vital Statistics Division

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