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a.
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Note: N6051 Given name (Sara), middle name (Elizabeth), surname (Berry) and status (deceased) in November, 1992, from Greene County Genealogy Project Obituary Board - Berry, Alice Post 1907-1992, posted by Laura Nelle Poland Mallett, http://www.pa-roots.org/data/read.php?412,494059, March 28, 2007
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OHIO DEPARTMENT OF HEALTH
COLUMBUS
CERTIFICATE OF DEATH
Department of Commerce - Bureau of the Census
Reg. Dist. No. __ 1206 __
Primary Reg. Dist. No. __ 8482 __
State File No. __ 51734 __
RegistrarÕs No. __ 854 __
1. PLACE OF DEATH
(a) County ___ Stark ___
(b) ___ Canton ___
(City, Village, Township)
(c) Name of hospital or institution:
___ Mercy Hospital ___
(If not in hospital or institution, write street No. or location)
(d) Length of stay: In hospital or institution ___ 1 ___ (Days)
In this community __________ (Years, months or days)
2. USUAL RESIDENCE OF DECEASED:
(a) State ___ Pennsylvania ___
(b) County __________
(c) City or village ___ Claysville ___
(If outside city or village, write RURAL)
(d) Street No. ___ 219 Irwin St ___
(If rural, give location)
(e) If foreign born, how long in U. S. A.? __________ years.
3. FULL NAME ___ Sara E. Berry ___
(a) If veteran, name war __________
(b) Social Security No. __________
4. Sex ___ F ___
5. Color or race ___ W ___
6. (a) Single, widowed, married,
divorced ___ Single ___
6. (b) Name of husband or wife __________
6. (c) Age of husband or wife if
alive _____ years
7. Birth date of deceased ___ January ___ (Month) ___ 9 ___ (Day) ___ 1943 ___ (Year)
8. AGE: Years __ 5 __ Months ____ Days ____
If less than one day ____ hr. ____ min
9. Birthplace ___ Washington ___ (City, town, or county) ___ Pennsylvania ___ (State or foreign country)
10. Usual occupation __________
11. Industry or business __________
Father
12. Name ___ Robert M. Berry ___
13. Birthplace ___ Eighty Four, ___ (City, town, or county) ___ Pennsylvania ___ (State or foreign country)
Mother
14. Maiden name ___ Alice R. Post ___
15. Birthplace ___ Niles ___ (City, town, or county) ___ Ohio ___ (State or foreign country)
16. (a) InformantÕs signature ___ Robert M. Berry ___
(b) Address ___ Claysville, Penn ___
17. (a) (a) Burial, cremation or other; (b) Date ___ August ___ (Month) ___ 25, ___ (Day) ___ 1948 ___ (Year)
(c) Place ___ Claysville, Penn ___ (NOTE: THE LOCATION OF BURIAL CONFLICTS WITH INFORMATION IN ANOTHER SOURCE)
(d) ___ A B Jackson ___ (Name of Embalmer) __ 3184A __ (Lic. No.)
18. (a) ___ A B Jackson ___ (Signature of Funeral Director) __ 935 __ (Lic. No.)
(b) Address ___ Minerva Ohio ___
19. (a) ___ 8/26/48 ___ (Date received local registrar)
(b) ___ Evelyn Ziegler ___ (RegistrarÕs signature)
MEDICAL CERTIFICATION
20. Date of death: Month __ August __ day __ 21st __
year __ 1948 __ hour __ 8 __ minute __ 55 PM __
21.I hereby certify that I attended the deceased from _____
___ Viewed after Death___, 19 __, to __________, 19 __:
that I last saw h ____ alive on __________, 19 __:
and that death occurred on the date and hour stated above.
Immediate cause of death ___ 1 Shock ___
___ 2 Cerebral Concussion ___
___ 3 Fractured ribs
Due to ___ 4 Blunt Force ___
___ 21 Aug 48 ___
Due to ___ 170C-0 ___
__________
Other conditions __________
(Include pregnancy within 3 months of death)
__________
Duration
__________
__________
__________
__________
__________
__________
__________
__________
Major findings of operation ___ None ___
_______________
_______________
Major findings of autopsy ___ None ___
_______________
Underline
the cause to
which death
should be
charged sta-
tistically.
22. If death was due to external causes, fill in the following:
(a) Accident, suicide, or homicide (specify) ___ Accident ___
(b) Date of occurrence ___ 100-0 21-Aug 48 ___
(c) Where did the injury occur? __________ (City or Village) ___ Carroll ___ (County) ___ Ohio ___ (State)
(d) Did injury occur in or about home, on farm, in industrial
place, in public place (circled)? ___ Rt 43 - North of Carrollton ___
(Specify type of place)
While at work? ___ No ___ (e) How did injury occur? ___ Auto ___
___ Auto Collision ___
23. Signature ___ [?]le[?]eno M D ___
(Specify if Doctor of Medicine or Osteopathy (lined out))
Address ___ Coroner ___ Date signed ___ 22 Aug 48 ___
MARGIN RESERVED FOR BINDING
THIS CERTIFICATE SHALL BE PRINTED LEGIBLY OR TYPEWRITTEN IN UNFADING INK
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The following inscription is from a picture of her monument on Find A Grave (http://www.findagrave.com), United Presbyterian Cemetery, Washington, Washington County, Pennsylvania, Sarah Elizabeth Berry, added January 30, 2008, Memorial #24272897, created by Rebecca Berry Quay:
SARA ELIZABETH
BERRY
1943 - 1948
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