Texas State Board of Health

STANDARD CERTIFICATE OF DEATH

Registered No. 1973 24740

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PLACE OF DEATH

County Harris
City Cross Timbers
(No. _______________St.; ________________ Ward)
(If death occurred in a hospital or institution, give its NAME insteaqd of street and number.)

FULL NAME John Milton Morin DEATH OUTSIDE HOUSTON

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PERSONAL AND STATISTICAL PARTICULARS

SEX Male

COLOR OR RACE White

SINGLE, MARRIED, WIDOWED, OR DIVORCED (Write the Word.) single

DATE OF BIRTH ____________________ ______________

AGE 96 yrs _____ mos ______ ds.

OCCUPATION (a) Trade, profession, or particular kind of work _____________________
(b) General nature of industry, business or establishment in which employed (or employer) _____________________

BIRTHPLACE
(State or country) Kentucky

PARENTS

NAME OF FATHER Morin

BIRTHPLACE OF FATHER Kentucky

MAIDEN NAME OF MOTHER

BIRTHPLACE OF MOTHER (State or country)

THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ____________________________________________
(Address) _____________________________________________

Filed Dec 12 1914

O.C. GERHARDT
Registrar

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MEDICAL PARTICULARS

DATE OF DEATH Dec 11, 1914

I HEREBY CERTIFY, that I attended deceased from ___________________, 191___, to _______________, 191___ that I last saw h___ alive on _______________________, 191___ and that death occurrded on the date stated above at _____________m.
The CAUSE OF DEATH* was as follows.
Senility
(Duration) _________ yrs ______________ mos ___________ ds.
Contributory (Secondary) __________________________________
(Duration) _________ yrs ______________ mos ___________ ds.
(Signed) R. T. Scott, M.D.
12-12, 1914 (Address) [City?]
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*State the Disease Causing Death, or, in deaths from Violent Causes, state (1) Means of Injury, and (2) whether Accidental, Suicidal or Homicidal.
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LENGTH OF RESIDENCE (For Hospitals, Institutions, Transients or Recent Residents.)
At place of death _____ yrs _____ mos _____ ds. In the State _____ yrs _____ mos _____ ds.
Where was disease contracted if not at place of death? __________________________
Former or usual residence _____________________________

PLACE OF BURIAL OR REMOVAL Greens Bayou

DATE OF BURIAL Dec 12, 1914

UNDERTAKER Sid Westheimer Co.

ADDRESS Caroline & Prairie St.