Death Certificate

Reg. Dist. No. 57 
Primary Reg. Dist. No. 5701

State File No. 
Registrar's No. 2941

DECEASED-NAME 
1. Augusta M. Roads

SEX 
2. Female

DATE OF DEATH 
3. July 7, 1972

RACE 
4. White

AGE 
5a. 76

UNDER 1 YEAR 
5b.

UNDER 1 DAY 
5c.

DATE OF BIRTH 
6. 3/18/96

COUNTY OF DEATH 
7a. Montgomery

CITY, VILLAGE, OR LOCATION OF DEATH 
7b. Dayton

INSIDE CITY LIMITS 
7c. Yes

HOSPITAL OR OTHER INSTITUTION-Name 
7d. Good Samartian

STATE OF BIRTH 
8. Ohio

CITIZEN OF WHAT COUNTRY 
9. U.S.A.

MARRIED, NEVER MARRIED, 
WIDOWED, DIVORCED 
10. Married

SURVIVING SPOUSE 
11. Wilbert O. Roads

SOCIAL SECURITY NUMBER 
12a. 288 07 2724

WAS DECEASED EVER IN U. S. ARMED FORCES? 
12b. no

USUAL OCCUPATION 
13a. Home maker

KIND OF BUSINESS OR INDUSTRY 
13b. Own Home

RESIDENCE-STATE 
14a. Ohio

COUNTY 
14b. Montgomery

CITY, VILLAGE OR LOCATION 
14c. Brookville

INSIDE CITY LIMITS 
14d. yes

STREET AND NUMBER 
14e. 305 Arlington Rd.

FATHER-NAME 
15. Gustave Reiniger

MOTHER-MAIDEN NAME 
16. Lena Praeg

INFORMANT-NAME 
17a. Wilbert O. Roads

MAILING ADDRESS 
17b. 305 Arlington Rd., Brookville, Ohio 45309

PART 1. DEATH WAS CAUSED BY

APPROXIMATE INTERVAL 
BETWEEN ONSET AND DEATH

18. IMMEDIATE CAUSE 
(a) Cerebral Anoxia
DUE TO, OR AS A CONSEQUENCE OF: 
(b) Cardiac Arrest 
DUE TO, OR AS A CONSEQUENCE OF: 
(c) Arteriosclerotic and hypertensive Cardiovascular disease

PART II. OTHER SIGNIFICANT CONDITIONS 
Arteriosclerosis abdominal Aorta

AUTOPSY 
19a. No

IF YES were findings considered
indetermining cause of death 
19b. -

ACCIDENT, SUICIDE, HOMICIDE,
OR UNDETERMINED
20a.

DATE OF INJURY 
20b.

HOUR 
20c.

HOW INJURY OCCURRED 
20d.

INJURY AT WORK 
20e.

PLACE OF INJURY 
20f.

LOCATION 
20g.

CERTIFICATION-PHYSICIAN  
I ATTENDED THE  
21a. DECEASED FROM 7-7-72

TO  
21b. 7-7-72

AND LAST SAW HIM/HER  
ALIVE ON  
21c. 7-7-72

I DID/DID NOT  
VIEW THE BODY  
AFTER DEATH.  
21d. DID

DEATH OCCURRED (HOUR)  
21e. 11:20 PM.

CERTIFICATION-CORONER  
22e.

Hour of death  

The decedent was pronounced dead  
22b. July 7, 1972 11:20 PM.

CERTIFIER-NAME  
23a. DAVID A. GARRETY, M. D.
NORTH LUDLOW ST.
PHILLIPSBURG, OHIO

SIGNATURE  
23b. David A. Garrety MD

DATE SIGNED  
23c. 7-11-72

MAILING ADDRESS-CERTIFIER  
23d. 

BURIAL, CREMATION 
24a. Burial

DATE  
24b. 7/11/72

NAME OF CEMETERY OR CREMATORY  
24c. Arlington Cemetery

LOCATION  
24d. Brookville, Ohio 45309

NAME OF EMBALMER  
25. Robert L. Gilbert

FUNERAL DIRECTOR'S SIGNATURE  
26. Robert L. Gilbert

FUNERAL FIRM AND ADDRESS  
27. Rogers & Gilbert Funeral Homes, Inc., Brookville, Ohio, 45309

DATE REC'D BY  
LOCAL REG  
28. 7/13/72

REGISTRAR'S SIGNATURE  
29. Sylvia Christ

DATE PERMIT ISSUED  
30.

SIGNATURE OF PERSON ISSUING PERMIT  
31.

DIST. NO.