Death Certificate

Reg. Dist. No. 57 
Primary Reg. Dist. No. 5700

State File No. 
Registrar's No. 4762

DECEASED-NAME 
1. Wilbert O. Roads

SEX 
2. Male

DATE OF DEATH 
3. November 2, 1984

RACE 
4. White

AGE 
5a. 89

UNDER 1 YEAR 
5b.

UNDER 1 DAY 
5c.

DATE OF BIRTH 
6. Sept. 28, 1895

COUNTY OF DEATH 
7a. Montgomery

CITY, VILLAGE, OR LOCATION OF DEATH 
7b. New Lebanon

HOSPITAL OR OTHER INSTITUTION-Name 
7c. Royal Villa Care Center

IF HOSP,OR INST,indicate DOA, 
OP/Emer.Rm.,Inpatient 
7d. Inpatient

STATE OF BIRTH 
8a. Ohio

CITIZEN OF WHAT COUNTRY 
8b. U.S.A.

ORIGIN OR DESCENT 
9. German-Irish

SOCIAL SECURITY NUMBER 
10. 288-07-2724

WAS DECEASED EVER IN U.S. ARMED FORCES? 
11. No

MARRIED, NEVER MARRIED, 
WIDOWED, DIVORCED 
12a. Widowed

SURVIVING SPOUSE 
12b.

USUAL OCCUPATION 
13a. (Retired) Florist

KIND OF BUSINESS OR INDUSTRY 
13b. Roads Pansy Gardens

RESIDENCE-STATE 
14a. Ohio

COUNTY 
14b. Montg. Co.

CITY, VILLAGE OR LOCATION 
14c. New Lebanon

STREET AND NUMBER 
14d. 101 Mills Place

INSIDE CITY LIMITS 
14e. Yes

FATHER-NAME 
15. Frank Roads

MOTHER-MAIDEN NAME 
16. Ida Hull

INFORMANT-NAME 
17a. Mr. Kermit R. Roads

MAILING ADDRESS 
17b. 9480 Snake Rd., Dayton, Ohio 45426

PART 1. DEATH WAS CAUSED BY

APPROXIMATE INTERVAL 
BETWEEN ONSET AND DEATH

18. IMMEDIATE CAUSE 
(a) Cardiac Arrest 
DUE TO, OR AS A CONSEQUENCE OF: 
(b) Acute Myocardial Infarction 
DUE TO, OR AS A CONSEQUENCE OF: 
(c) Chronic Coronary Artery Disease

PART II. OTHER SIGNIFICANT CONDITIONS 
C A Prostate

AUTOPSY 
19a. No

WAS CASE REFERRED TO CORONER  
19b. No

ACC., SUICIDE, HOM., UNDET., 
OR PENDING INVEST. 
20a.

DATE OF INJURY 
20b.

HOUR 
20c.

HOW INJURY OCCURRED 
20d.

INJURY AT WORK 
20e.

PLACE OF INJURY 
20f.

LOCATION 
20g.

21a. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) 
stated. 
Milo Phillips MD

22a. On the basis of examination and/or investigation, in my opinion death occurred at the time, date 
and place and due to the cause(s) stated.

DATE SIGNED 
21b. 11-5-84

HOUR OF DEATH 
21c. 1:40 P. M

DATE SIGNED 
22b.

HOUR OF DEATH 
22c.

Milo Phillips, MD

PRONOUNCED DEAD 
22d. ON

PRONOUNCED DEAD 
22e. AT

NAME AND ADDRESS OF CERTIFIER (PHYSICIAN OR CORONER) 
23. 220 E. Main St., New Lebanon, Ohio 45545

BURIAL, CREMATION, 
Other 
24a. Burial

DATE  
24b. 11/5/84

NAME OF CEMETERY OR CREMATORY  
24c. Arlington Cemetery

LOCATION  
24d. Clay Twp., Brookville, Ohio

NAME OF EMBALMER  
25. Donald M. Keighley

FUNERAL DIRECTOR'S SIGNATURE  
26. Don Keighley

FUNERAL FIRM AND ADDRESS  
27. Gilbert Funeral Home, Inc., 3 Hay Ave., Brookville, Ohio 45309

DATE REC'D BY  
LOCAL REG  
28. 11/6/84

REGISTRAR'S SIGNATURE  
29. Barbara Bricosia

DATE PERMIT ISSUED  
30.

SIGNATURE OF PERSON ISSUING PERMIT  
31.

DIST. NO.