Death Certificate

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

State File No. 
Registrar's No. 2230

DECEASED-NAME 
1. MIRIAM ALICE LEE

SEX 
2. Female

DATE OF DEATH 
3. May 30, 1975

RACE 
4. White

AGE 
5a. 59

UNDER 1 YEAR 
5b.

UNDER 1 DAY 
5c.

DATE OF BIRTH 
6. OCT. 26, 1915

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 Samaritan Hospital

STATE OF BIRTH 
8. Ohio

CITIZEN OF WHAT COUNTRY 
9. Usa

MARRIED, NEVER MARRIED, 
WIDOWED, DIVORCED 
10. Married

SURVIVING SPOUSE 
11. James Lee

SOCIAL SECURITY NUMBER 
12a. 292-01-2585

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

USUAL OCCUPATION 
13a. Bookeeper

KIND OF BUSINESS OR INDUSTRY 
13b. Guild & Landis Welding

RESIDENCE-STATE 
14a. Ohio

COUNTY 
14b. Montgomery

CITY, VILLAGE OR LOCATION 
14c. Trotwood

INSIDE CITY LIMITS 
14d. Yes

STREET AND NUMBER 
14e. 308 Carthage Place

FATHER-NAME 
15. Charlas Shank

MOTHER-MAIDEN NAME 
16. Maude Neff

INFORMANT-NAME 
17a. Kenneth Lee

MAILING ADDRESS 
17b. 308 Carthage Place, Trotwood, Ohio, 45426

PART 1. DEATH WAS CAUSED BY

APPROXIMATE INTERVAL 
BETWEEN ONSET AND DEATH

18. IMMEDIATE CAUSE 
(a) Acute Pancreatitis with multiple abuses 
DUE TO, OR AS A CONSEQUENCE OF: 
(b) 
DUE TO, OR AS A CONSEQUENCE OF: 
(c)

4 wks.

PART II. OTHER SIGNIFICANT CONDITIONS 
Hypertension and Hyperencephalopathy

AUTOPSY 
19a.

IF YES were findings considered 
in determining 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 5-7-75

TO 
21b. 5-30-75

AND LAST SAW HIM/HER 
ALIVE ON 
21c. 5-30-75

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

DEATH OCCURRED (HOUR) 
21e. 5 25 PM.

CERTIFICATION-CORONER 
22e.

Hour of death 

The decedent was pronounced dead 
22b.

CERTIFIER-NAME 
23a. A. B. Hupper

SIGNATURE 
23b. A B Hupper MD

DATE SIGNED 
23c. 6/2/75

MAILING ADDRESS-CERTIFIER 
23d. 920 Fidelity Bldg, Dayton, Ohio 45402

BURIAL, CREMATION 
24a. Burial

DATE 
24b. 6/3/75

NAME OF CEMETERY OR CREMATORY 
24c. Arligton Cemetery

LOCATION 
24d. Montgomery Co., Ohio

NAME OF EMBALMER 
25. Emerson Lee Rogers

(LIC. NO.) 
5631-A

FUNERAL DIRECTOR'S SIGNATURE 
26. Dean Rogers

(LIC. NO.) 
6366

FUNERAL FIRM AND ADDRESS 
27. Rogers Funeral Home, Inc., 110 West Main Street, Trotwood, Ohio, 45426

DATE REC'D BY 
LOCAL REG 
28. 6/3/75

REGISTRAR'S SIGNATURE 
29. Sylvia Christ

DATE PERMIT ISSUED 
30.

SIGNATURE OF PERSON ISSUING PERMIT 
31.

DIST. NO.