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Note: N5114 A receipt from George Church to Ralph Porter contains the following information:
Jan. 9 1941
Received of Ralph E. Porter
- Twenty and no/100 - Dollars
For - grave at Greenmount & Burial
in full
$20.00 Thanks Geo. I. Church
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The Lot Book (G98S-page 2) of Green Mount Cemetery Association (provided by Candice Buchanan) contains the following:
Single Graves Sec G.
Infant Porter daughter of
Ralph Porter
Single Grave #647
Stillborn Jan. 2 (sic), 1941. (NOTE: THE DAY OF DEATH CONFLICTS WITH INFORMATION FOUND IN ANOTHER SOURCE)
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HVS-5-100M-1-39 COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH
BUREAU OF VITAL STATISTICS __ 636 __
CERTIFICATE OF DEATH
Primary Dist. No. __ 30-05-41 __
File No. __ 04582 __
Registered No. __ 5 __
1. PLACE OF DEATH
County ___ Greene ___
Township __________
Borough ___ Waynesburg ___
City __________
No. __________ St., ______ Ward.
(If death occurred in a HOSPITAL or INSTITUTION, give its NAME instead of street and number)
Length of residence in city or town where death occurred ____ yrs. ____ mos. ____ days.
How long in U. S., if of foreign birth? ____ yrs. ____ mos. ____ days.
(IF U. S. VETERAN, COMPLETE REVERSE SIDE OF CERTIFICATE)
2. FULL NAME (type or print) ___ Still-born - Porter ___
Residence: No. __________ St., ______ Ward. __________
(Usual place of abode) (If nonresident, give place, county, and State)
PERSONAL AND STATISTICAL PARTICULARS
3. SEX ___ F. ___
4. COLOR OR RACE ___ W ___
5. SINGLE, MARRIED, WIDOWED,
OR DIVORCED (write the word) ___ - ___
5a. If married, widowed, or divorced
HUSBAND of
(or) WIFE of ___ - ___
6. DATE OF BIRTH (month, day, and year) ___ Jan. 9- 1941 ___
7. AGE ____ Years ____ Months ____ Days
IF LESS than 1 day,
___ hrs. or ___ mins.
OCCUPATION
8. Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc. ___ - ___
9. Industry or business in which
work was done, as silkmill,
sawmill, bank, etc. ___ - ___
10. Date deceased last worked at
this occupation (month
and year) __________
11. Total time (years)
spent in this
occupation __________
12. BIRTHPLACE (city or town) __________
(State or Country) ___ Pa. ___
FATHER
13. NAME ___ Ralph E. Porter ___
14. BIRTHPLACE (city or town) __________
(State or Country) ___ Pa. ___
MOTHER
15. MAIDEN NAME ___ Margaret E. Berryhill ___
16. BIRTHPLACE (city or town) __________
(State or Country) ___ Pa. ___
17. SIGNATURE OF INFORMANT ___ Ralph E. Porter ___
(Address) ___ Waynesburg Pa. ___
18. BURIAL, CREMATION, OR REMOVAL: Date __ Jan. 10 __, 19 _ 41 _
Place ___ Greenmont ___ County ___ Greene ___ State ___ Pa. ___
19. UNDERTAKER (name and address)
___ Geo. I. Church - Waynebsurg Pa. ___
20. FILED ___ Jan 10 ___, 19 _ 41 _
___ Beatrice D. Manning ___
Registrar.
MEDICAL CERTIFICATE OF DEATH
21. DATE OF DEATH ___ Jan. 9 ___, 19 _ 41 _
(month. day, and year)
22. I HEREBY CERTIFY, That I attended deceased from
___ Jan 9 ___, 19 _ 41 _, to ___ Jan 9 ___, 19 _ 41 _
I last saw h _ er _ alive on ___ Still Born 1/9/ ___, 19 _ 41 _; death is said
to have occurred on the date stated above, at ___ 11 a ___ m.
The principal cause of death and related causes of importance were
as follows:
___ Still-Born - ___
____________________
____ 444 ____
____________________
Other contributory causes of importance:
___ Influenza ___
___ Mother. ___
____________________
Date of
onset
__________
__________
__________
__________
__________
__________
__________
Name of operation ___ none ___ Date of __________
What test confirmed diagnosis ___ Examination ___ Was there an autopsy? ___ no ___
23. If death was due to external causes (violence), fill in also the following:
Accident, suicide, or homicide? ___ no __ Date of injury _______, 19 __
Where did injury occur? ___ none ___
(Specify city or town, county, and State)
Specify whether injury occurred in industry, in home, or in public place:
________________________
Manner of injury ___ none ___
Nature of injury __________
24. Was disease or injury in any way related to occupation of deceased? ___ no ___
If so, specify ___________
(Signed) ___ H C Scott ___ M. D.
D. O.
___ 1/10/41 ___ 19 __ (Address) ___ Waynesburg Pa. ___
MARGIN RESERVED FOR BINDING
WRITE PLAINLY WITH UNFADING INK - THIS IS A PERMANENT RECORD
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE
OF DEATH in plain terms, so that it may be properly classified. Exact Statement of OCCUPATION is very important. See instruc-
tions on back of certificate.
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