Death Certificate

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

State File No. 
Registrar's No. 2342

1. PLACE OF DEATH  
a. COUNTY Montgomery

2. USUAL RESIDENCE  
a. STATE Ohio b. COUNTY Montgomery

b. CITY, VILLAGE, OR LOCATION 

c. LENGTH OF STAY IN 1b 

c. CITY, VILLAGE OR LOCATION 

d. NAME OF  
HOSPITAL OR  
INSTITUTION Good Samaratin Hospital

d. STREET ADDRESS 

e. WAS PLACE OF DEATH INSIDE CITY LIMITS?  
YES X NO -

e. IS RESIDENCE INSIDE CITY LIMITS?  
YES X NO -

f. IS RESIDENCE A FARM?  
YES - NO X

3. NAME OF  
DECEASED Mabel E. Thompson

4. DATE  
OF  
DEATH 7/14/1967

5. SEX 

6. COLOR OR RACE 

7. MARRIED - NEVER MARRIED -  
WIDOWED X DIVORCED -

8. DATE OF BIRTH  

9. AGE 

If Under 1Year

If Under 24 Hrs

10. USUAL OCCUPATION  

10b. KIND OF BUSINESS OR INDUSTRY

11. BIRTHPLACE  

12. CITIZEN OF  
WHAT COUNTRY? 

13. FATHER'S NAME 

14. MOTHER'S MAIDEN NAME 

15. WAS DECEASED EVER IN U. S. ARMED FORCES?  

16.SOCIAL SECURITY NO.

17. INFORMANT'S SIGNATURE 

MEDICAL CERTIFICATION

18. CAUSE OF DEATH  
PART I. DEATH WAS CAUSED BY:  
IMMEDIATE CAUSE (a) Cerebral thrombosis 
DUE TO (b)  
DUE TO (c)

INTERVAL BETWEEN  
ONSET AND DEATH 
week

PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART I(a)
Congestive ???

19. WAS AUTOPSY  
PERFORMED?  
YES - NO X

20a. ACCIDENT

SUICIDE

HOMICIDE

20b.DESCRIBE HOW INJURY OCCURRED

20c. TIME OF INJURY

20d. INJURY OCCURRED 

20e. PLACE OF INJURY

20f. CITY, VILLAGE, OR LOCATION

WHILE AT  
WORK -

NOT WHILE  
AT WORK -

21. I attended the deceased from June 67 to death and last saw her alive on  7-14-67
and death occurred at    m onthedate stated in 4, and to the best of my knowledge, from the causes stated.

22a. SIGNATURE 

22b. ADDRESS  

22c. DATE SIGNED 

23a. BURIAL, CREMA-  
TION 

23b. DATE  

23c. NAME OF CEMETERY OR CREMATORY 

23d. LOCATION  

24. NAME OF EMBALMER 

(LIC. NO.)  
4415 A

25. FUNERAL DIRECTOR'S SIGNATURE 
???

(LIC. NO.) 
3629

26. FUNERAL FIRM AND ADDRESS 

27. DATE REC'D BY  
LOCAL REG.  

28. REGISTRAR'S SIGNATURE 

29. DATE REC'D BY
SUB-REGISTRAR

30. SUB-REGISTRAR'S SIGNATURE