John William Myers Sr.
Death Certificate
4 November 1936

Text of the Document

Click image below for high-resolution version

Document

Text of the Document

Hand-written items are underscored; added notes are {italicized-bracketed}.

STATE OF OHIO

DEPARTMENT OF HEALTH

DIVISION OF VITAL STATISTICS

CERTIFICATE OF DEATH

1  PLACE OF DEATH
            County Pickaway   Registration District No. 1031   File No. 73421
            Township Deer Creek   Primary Registration District no. 5675   Registered No. _____
            or Village _____   No._____, _____St., _____Ward (If death occurred in a hospital or institution, give its NAME instead of street and number)
            or City of _____
            Length of residence in city or town where death occurred _____yrs. _____mos. _____da.   How long in U.S., if of foreign birth? _____yrs. _____mos. _____da.

2  FULL NAME John William Myers   Did Deceased Serve in U. S. Navy or Army _____
            (a) Residence. No._____, _____St., _____Ward   DEC 1936 (If nonresident give city or town and State)

PERSONAL AND STATISTICAL PARTICULARS
            3. SEX Male   4. COLOR OR RACE White   5. Single, Married, Widowed, or Divorced (write the word) Married   5a. If married, widowed, or divorced HUSBAND of (or) WIFE of Etta Myers   6. DATE OF BIRTH (month, day, and year) Jan 22, 1870   7. AGE Years 66 Months 9 Days 12 If LESS than 1 day, _____hrs. or _____min.
            OCCUPATION 8. Trade profession, or particular kind of work done, as spinner, sawyers, bookkeeper, etc. Farmer   9. Industry or business in which work was done, as silk mill, saw mill, bank, etc. VVN{?}   10. Date deceased last worked at this occupation (month and year) _____   11. Total time (years) spent in this occupation _____
            12. BIRTHPLACE (city or town) Bloominburg{Bloomingburg} (state or country) Ohio
            FATHER 13. NAME John Jacob Myres{John Jacob Myers} 14. Birthplace (city or town) Bloominburg{Bloomingburg} (state or country) O{Ohio}
            MOTHER 15. MAIDEN NAME Mary A. McCafferty 16. Birthplace (city or town) Fayette Co. (state or country) Ohio
            17. The Signature of INFORMANT Mrs. John Myers and (Address) Williamsport, O.{Ohio}   18. BURIAL, CREMATION, OR REMOVAL Place Columbus, O.{Ohio} Date Nov 7 1936   19. UNDERTAKER S. B. Metzer{?} (Address) Yes Williamsport   19a. Was body embalmed yes Embalmer's No. 34420   20. FILED 11/7 1936 Fred L. Tipton Resistrar.

MEDICAL CERTIFICATE OF DEATH

21. DATE OF DEATH (month, day, and year) 11/4, 1936,   22. I HEREBY CERTIFY, That I attended deceased from 11/4, 1936, to 11/4, 1936. I last saw him alive on 11/4, 1936 death is said to have occurred on the date stated above at 5:30 P.m. The PRINCIPAL CAUSE OF DEATH and related causes of importance in order of onset were as follows: Arterio Oclerosis 94a Date of onset _____   CONTRIBUTORY CAUSES of importance no related to the principal cause: Angina Pectoris Date of onset_____   Name of operation__-__ Date of_____ What test confirmed diagnosis?__-__ Was there an autopsy?_____   23 If death was due to external causes (violence) fill in also the followin: Accident, suicide, or homicide?__-__ Date of injury_____, 19__ Where did injury occur?__-__ (Specify city or town, county, and State) Specify whether injury occurred in industry, in home, or in public place._____ Marrer of injury__-__ Nature of injury__-__   24. Was disease or injury in any way related to occupation of deceased?NO If so, specify_____ (Signed) G. D. Sheets M. D. Date11/4 1936 AddressWilliamsport O.{Ohio}