• Individual
• Ancestors
• Descendants
• Relationship
• Timeline
• Family
• GEDCOM
• Suggest

USA-IL-A-00008 Death Certificate Walter Johnston (1897-1973)

Note: Hand-written, typed or stamped text is enclosed in brackets ({ }) below. If an underlined entry field was left blank, it is indicated as {(no entry)}. State of Illinois Medical Certificate of Death State File Number: {73 044094} Registration District No. {49.8} Registered Number: {880} 1. Deceased Name: {Walter Johnston} 2. Sex: {Male} 3. Date of Death: {August 18, 1973} 4. Race: {White} 5. Age (last birthday): {76} 6. Date of Birth: {July 13, 1897} 7. Place of Death (County): {Lake} 8. Birthplace (State or foreign country): {Illinois} 9. Citizen of what country? {USA} 10. Married, Never Married, Widowed, Divorced: {Widowed} 11. Name of Surviving Spouse: {(no entry)} 12. Social Security Number: {349 09 4285} 13. (a) Usual Occupation: {Guard} (b) Kind of businss or industry: {Factory} (c) U. S. War Veteran: {No} (d) War or dates of service: {(no entry)} 14. Residence (a) State: {Illinois} (b) County: {Lake} (c) City, Town or Road District No.: {Lake Villa} (d) Inside City: {Yes} (e) Street and Number: {259 Grand Avenue} ___________________________________ 15. Father Name: {George Henry Johnston} 16. Mother Name: {Martha Boezel} ___________________________________ 17. Informant (a) Signature: {Elsie M. Schultz} (b) Relationship: {Daughter In-Law} (c) Mailing Address: {7N041 Medinah Rd. Medinah, Illinois 60157} ___________________________________ 18. Death was caused by (approximate interval between onset and death) - Part I. (a) Immediate cause: {Broncho-Pneumonia (10 days)} - Due to or as a consequence of (b) {Recurrent Epidermoid Carcinoma Larynx (18 months)} - Part II. Other significant conditions: {None} 19. Autopsy: {No} 20. (a) Date of Operation, if any: {July 1 - 72} (b) Major Findings of Operation: {Carcinoma Larynx} ___________________________________ 21. I attended the deceased (a) from: {6-15-72} (b) to {8-18-73} (c) and last saw him/her alive on {8-18-73} (d) Hour of death: {7:20 P} M 22. (a) Signature {(illegible)} (b) Date Signed: {August 20, 1973} (c) License Number {36-34111} 23. Mailing Address: {609 Greenwood Avenue Waukegan Illinois 60085} ___________________________________ 24. (a) Burial, Cremation, Removal: {Burial} (b) Cemetery or Crematory: {Cedar Park} (c) Location: {Chicago, Illinois} (d) Date {August 21, 1973} 25. Funeral Home (a) Name and Address: {MacGillis Funeral Home 350 Goodnow Blvd. Round Lake, Illinois 60073} (b) Signature: {Douglas A. MacGillis} (c) Illinois License Number: {5147} ___________________________________ 26. (a) Local Registrar's Signature: {?H. A. Guthrie?} (b) Date Rec'd by Local Registrar: {Aug. 20, 1973}