Elizabeth McDANIEL (Bastin) Death Certificate

Elizabeth McDANIEL (Bastin) Death Certificate

 

Indiana State Board of Health

Certificate of Death

 

Place of Death:

County of Morgan

Township of [blank]

Village of [blank]

or

City of Martinsville (No. [blank], [blank] St.; [blank] Ward]

Registered No. 72

 

FULL NAME Elizabeth Bastin

 

PERSONAL AND STATISTICAL PARTICULARS

SEX: Female

COLOR: White

DATE OF BIRTH: Nov. 6, 1835

AGE: 75 years, 11 months, 29 days

SINGLE...: Widow

NAME OF HUSBAND: Henry A. Bastin

BIRTHPLACE OF DECEASED: Indiana

NAME OF FATHER: James McDaniel

BIRTHPLACE OF FATHER: North Carolina

MAIDEN NAME OF MOTHER: Matilda Lewis

BIRTHPLACE OF MOTHER: North Carolina

OCCUPATION OF DECEASED: Housekeeper

 

The above stated personal particulars are true to the best of my knowledge and belief:

(Informant) H. M. Bastin

(Address) R. R. No. 8, Martinsville

 

Burial Permit Issued by: F. R. Maxwell

 

MEDICAL CERTIFICATE OF DEATH:

DATE OF DEATH: Nov. 4, 1911

I HEREBY CERTIFY, That I attended deceased from Nov 3, 1911 to Nov 4 1911 that I last saw her alive on Nov 3, 1911 and that death occurred, on the date stated above, at 3 P.M. The CAUSE OF DEATH was as follows:

Influenza

[blank] (Duration) [blank] (Days)

Contributory [blank]

[blank] (Duration) [blank] (Days)

(Signed) A. A. Sweet, M.D.

Nov 4, 1911 (Address) Martinsville, Ind

 

PLACE OF BURIAL OR REMOVAL: Ellettsville

DATE OF BURIAL: Nov. 6, 1911

UNDERTAKER: Wilhite & Sons

NO. OF LICENSE: 845

ADDRESS: Martinsville

WAS THE BODY EMBALMED? Yes

 

 

Transcription by John C. Hepner, 1998

 

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