The following is my transcription of the death certificate of Rebecca Ann Ott, wife to Samuel G. Ott, of Canal Fulton, Ohio.
DEATH CERTIFICATE OF Rebecca Ann Ott
STATE OF OHIO
BUREAU OF VITAL STATISTICS
CERTIFICATE OF DEATH
1 PLACE OF DEATH
County Portage Registration District No. 1058 File No.
Township Primary Registration District No. 8415 Registered No. 44255
or Village No. , St., Ward
or City of Kent, Ohio (If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME Rebecca Ann Ott
(a) Residence. No. St., Ward
(Usual place of abode) (If nonresident, give city or town and State)
Length of residence in city or town where death occurred yrs. mos. ds. How long in U.S., if of foreign birth? yrs. mos. ds.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED or DIVORCED (write the word) 5a If married, widowed or divorced
Female White Married HUSBAND of Samuel G. Ott
(or) WIFE of
6 DATE OF BIRTH (month, day, and yer) Jan. 2nd, 1846
7 AGE Years Months Days If LESS than 1 day hrs. or min.
8 OCCUPATION OF DECEASED
(a) Trade, profession or particular kind of work Housewife
(b) General nature of Industry, business, or establishment in which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (city or town) Canal Fulton State or country O
10 NAME OF FATHER Joseph Kirk
11 BIRTHPLACE OF FATHER (city or town) (State or country) Unknown
12 MAIDEN NAME OF MOTHER Unknown
13 BIRTHPLACE OF MOTHER (city or town) Canal Fulton (State or country) Ohio
14 Informant Samuel G. Ott
(Address) Canal Fulton, O
15 Filed 8/19, 1922 Frank Bechiter Registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day and year) Aug. 16, 1922
17 I HEREBY CERTIFY, that I attended deceased from , 1917, to Aug. 16th, 1922
that I last saw her alive on July 15th, 1922 and that death occurred, on the date stated above, at 8oo P.m.
The CAUSE OF DEATH* was as follows: Myxedima (duration) yrs. mos. ds.
CONTRIBUTORY (secondary) Unknown (duration) yrs. mos. ds.
18 Where was the disease contracted if not at the place of death?
Did an operation precede death? No Date of
Was there an autopsy? No
What test confirmed diagnosis? Physical exam
(Signed) Hiram Bessinger, M.D.
Aug. 17th, 1922 (Address) Canal Fulton, O
State the Disease Causing Death, or in deaths from Violent Causes, state (1) Means and Nature of Injury, and (2) whether Accidental, Suicidal or Homicidal. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION OR REMOVAL DATE OF BURIAL
Union Cemetery, Canal Fulton, O Aug. 19, 1922
20 UNDERTAKER, License No. ADDRESS
The Finefrock Bros. Co. Canal Fulton, O.
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