Death Certificate

U. S. DEPARTMENT OF COMMERCE BUREAU OF CENSUS		STATE OF OHIO DEPARTMENT OF HEALTH CERTIFICATE OF DEATH
1 PLACE OF DEATH County MONTGOMERY Township Jefferson or Village or City of DAYTON		Registration District No. 904 Primary Registration District No. 5374 No -, - St., - Ward		File No. 1178 Registered No.
Length of residence in city or town where death occurred - yrs, - mos, 10 ds.			How long in U. S., if of foreign birth? - yrs., - mos., - ds.
2 FULL NAME Ida Elizabeth Roads			Did Deceased Serve in U. S. Navy or Army
(a) Residence. No., Dayton, Ohio R. R. 4			Ward
PERSONAL AND STATISTICAL PARTICULARS			MEDICAL CERTIFICATE OF DEATH
3. SEX F	4. COLOR or RACE W	5. SINGLE, MARRIED W	21. DATE OF DEATH 5-9, 1940
5a. If Married, Widowed, or Divorced Husband of (or) Wife of Frank Roads			22. I HERBY CERTIFY, That I attended deceased from 5-1, 1940 to 5-8, 1940. I last saw her alive on 5-8, 1940, death is said to have occurred on the date stated above at 1:00 am.
6. DATE OF BIRTH Oct. 17, 1861
7. AGE (years) Months Days 78 6 22		If LESS than 1 day, - hrs, or - min.	The PRINCIPAL CAUSE OF DEATH and related causes of importance in order of onset were as follows: Arterio sclerosis Cerebral Hemorrhage	Date of onset 5/6/40
OCCUPATION	8. Trade, profession, or particular kind of work done Housewife
	9. Industry or business in which work was done		CONTRIBUTORY CAUSES of importance not related to principal cause: Senility
	10. Date deceased last worked at this occupation	11. Total time (years) spent in this occupation	Name of operation	Date of
12. BIRTHPLACE Johnsville, Ohio			What test confirmed diagnosis?	Was there an autopsy? No
FATHER	13. NAME John Hull		23. If death was due to external causes (violence) fill in also the fol- lowing:
	14. BIRTHPLACE Johnsville, Ohio		Accident, suicide, or homicide?
MOTHER	15. MAIDEN NAME Martha Clayton		Where did injury occur?
	16. BIRTHPLACE Johnsville, Ohio		Specify whether injury occurred in industry, in home, or in public place.
17. The signature of INFORMANT Emma Gearhart and (Address) Dayton, Ohio, R. R. 4			Manner of injury
18. BURIAL, CREMATION OR REMOVAL Place Eversole Date May 11 1940			Nature of injury
19. FUNERAL FIRM Stubbs Fun. Home			24. Was disease of injury in any way related to occupation of deceased? No
19a. BURIED BY A. H. Stubbs Lic. No. 1699 Address Waynesville, Ohio			If so, specify
19b. EMBALMER A. H. Stubbs Lic. No. 3219			(Signed) V. H. Mahan
20. FILED 5/11, 1940		??? Registrar	Date 5/10, 1940	Address New Lebanon, Ohio

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last modified: 98.07.13