STATE OF ILLINOIS
STANDARD CERTIFICATE OF DEATH
Registered 228
Place of Death: St. Clair County
Dist. No. 855
City: Belleville
Primary Dist. No. 3646
Street and Number: Ill. Light & Power Co. Plant
Full Name: John Q. ADAMS
Residence: DuQuoin, Ill.
Length of residence in city where death occurred: 2 days
Sex: Male
Color or Race: White
Marital Status: Divorced
Spouse's Name: Myrtle ADAMS
Date of Birth: June 22, 1894
Age: 35 years, 1 month and 0 days
Occupation of Deceased: Electrician
Birthplace: Dongola, Ill.
Name of Father: Elmer ADAMS
Birthplace of Father: Dongola, Ill.
Maiden Name of Mother: Mary GORDON
Birthplace of Mother: Dongola, Ill.
Informant: Mrs. Myrtle ADAMS
P. O. Address: DuQuoin, Ill.
Filed July 23, 1929
E. J. EISENHAUER, Registrar
P. O. Address: Belleville, Ill.
Date of Death: July 22, 1929
I HEREBY CERTIFY, That I took charge of the remains the deceased herein described, held an inquest there and from the evidence obtained find that said deceased came to his death on the date stated abovce and that the cause of death was as follows:
Electric shcok received when he came in contact with high tension wire in power house at Belleville, Ill. Accidental death, occupational
Injury Rec'd in Belleville *City*
Signed: W. W. BOYNE
Address: E. St. Louis, Ill.
Cemetery: Duquoin *incorrect, possibly buried in Union County, Ill.
Location: Duquoin
Date: July 24, 1929
County: St. Clair
State: Ill.
Undertaker: H. W. SCHROEDER
Address: Duquoin
Donated by Virginia ADAMS PIERCE