Submitted by Sharon Foe
State of Ohio
BUREAU OF VITAL STATISTICS
Certificate of Death
Place of Death:
County of Lawrence County
Township of Winsor
Registration District No. 5057
FULL NAME: Selina Stephens
PERSONAL AND STATISTICAL PARTICULARS
SEX female COLOR OR RACE white
DATE OF BIRTH Dec. 4, 1842
AGE 73 years, 6 months 22 days
SINGLE, MARRIED, WIDOWED, OR DIVORCED: widowed
BIRTHPLACE: Ohio
OCCUPATION: House keeper
NAME OF FATHER: Enoch Johnson
BIRTHPLACE OF FATHER: Canada
MAIDEN NAME OF MOTHER: Elizabeth Butler
BIRTHPLACE OF MOTHER: Kentucky
THE ABOVE STATED PERSONAL PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF: WM. H. Stephens
(address) Willowwood, Ohio
FILED:June 16, 1916
O ? Williams, Registrar
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH: June 2(?), 1916
I HEREBY CERTIFY, THAT I ATTENDED DECEASED FROM
June 23, 1916 to June 25, 1916 that I saw ss alive on June 24, 1916 and that death occurred on the date stated above at 3 AM. The cause of death was as follows: Uressia poisioning duration 4 days
signed Casper Burton MD, 6/26/1916, Willowwood, O
PLACE OF BURIAL OR REMOVAL Locust Grove, DATE OF BURIAL June 27, 1916
UNDERTAKER; C E. Gruber (?) Willow Wood O
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