James Jefferson BOLIN Death Certificate

Indiana State Board of Health

Certificate of Death

Place of Death:

County of Marion

Township of Center

Village of [blank]

or

City of Indpls (No. 329, N. Beville St.; 9 Ward]

Registered No. 43

[stamped above: 45714]

FULL NAME: James J. Bolin

PERSONAL AND STATISTICAL PARTICULARS

SEX: Male

COLOR: White

SINGLE...: M.

NAME OF HUSBAND OR WIFE: Lettie Bolin

DATE OF BIRTH: Sept. 1, 1879

AGE: 39 years, 2 months, [blank] days

OCCUPATION:

(a) R. R. Conductor

(b) [blank]

BIRTHPLACE OF DECEASED: Indiana

NAME OF FATHER: Emanuel Bolin

BIRTHPLACE OF FATHER: Ind

MAIDEN NAME OF MOTHER: Annie Bastin

BIRTHPLACE OF MOTHER: Ind

THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE:

(Informant) Lettie Bolin

(Address) 329 N. Beville

Filed: DEC 4 1918 [stamped]

Name and Address of Health Officer or Deputy: [blank]

MEDICAL CERTIFICATE OF DEATH:

DATE OF DEATH: Dec 3, 1918

I HEREBY CERTIFY, That I attended deceased from Dec 3 1918 to Dec 3 1918 that I last saw him alive on Dec 3, 1918 and that death occurred, on the date stated above, at 5 P.M. The CAUSE OF DEATH was as follows:

Bronchial pneumonia

(Duration) [blank] yrs. [blank] mos. 5 ds.

Contributory: Influenza

(Duration) [blank] yrs. [blank] mos. 10 ds.

(Signed) H. A. Hutchinson, M.D.

[blank], 19[blank] (Address) Ennish [?]

PLACE OF BURIAL OR REMOVAL: Paragon Ind

DATE OF BURIAL: 12/6, 1918

WAS THE BODY EMBALMED? Yes

UNDERTAKER: Shirley Bros Co

ADDRESS: City

NO. OF LICENSE: 1465