Missouri State Board of
Health Bureau of Vital Statistics Certificate of Death 1. Place of
Death County_________________ Registration District No_______791__________ File No. ____18250____________ Township_______________ Primary Registration District No__1003_______ Registered No.___4461_________ City___St. Louis City____________________________ 2. Full Name___________William A. McMillin___________________________________________________________________________ Residence, No__________2512 No. 10th __________________________ Ward ___26_______________________ Length of residence in the city or town where death occurred____45____yrs_____mos_______days |
Personal and Statistical
Particulars 3. Sex______Male_____ 4. Color or Race____White______ 5. Single, Married, Widdowed, Divorced_____Married______ 5a. Husband or Wife of___________________________________________ 6. Date of Birth______Mar. 13th - 1869______ 7. Age Years____64______Months_____2_____days_____8______ 8. Trade, Profession_____Carpenter_____________________________ 9. Industry or Business_________________________________ 10. Date deceased last worked at this occupation__________________________ 11. Total time (years) spent in this occupation_____________________________ 12. Birthplace______St. Charles Co. ____________________________________________ 13. Father's Name_________John McMillin_____________________________________ 14. Father's Birthplace City or Town ___St. Charles Co. __________ State or Country___MO_________ 15. Mothers Maiden Name____Marceline Baltezor________________________________________ 16. Mother's Birthplace City or Town ____________________ State or Country___Canada________ 17. Informants Name and Address___Hospital Information Grace Kopp City Hospital____________ 18. Burial, Cremation, or Removal Place_____Memorial Park___ Date_____May 24, 1933_____ 19. Undertaker__Drehmann Harral_________Address_____1905 Union______ 20. Filed______May 22, 1933_____ |
Medical
Certificate of Death 21. Date of Death____May 21, 1933_____________________ 22. I HEREBY CERTIFY that I attended the deceased from ____April 6th, 1933_______to ________May 21st, 1933____ I last saw ____him__________alive ___May 21st, 1933________Death is said to have occurred on the date stated above at __6:30 PM _________________ The principal cause of death and related causes of importance were as follows: ____________________Streptococcic_____________________________ _____________________Septicemia________________________________ _________________Fell to the floor while dancing_______________________ Other contributary causes of importance: _____________________Infected Knee Joint__________________________ ______________________Fract. Patella_____________________________ Name of Operation____Open Reduction Patella_________ Date of ____3-18-33___ What test confirmed diagnosis____Clinical Laboratory_______ Was there an autopsy?____no____ 23. If death was due to external causes (violence), fill in also the following: Accident, Suicide, or Homicide?___accident_______ Date of injury__________________ When did injury occur?_________________________________ 24. Was disease or injury in any way related to occupation of deceased?___________ (signed)______Jerome Drimon , MD____________ (address)______City Hospital_________________ |