Harrell, Martin E

Posted By: J A Harrell
Date: 30 October 2003

State of Ohio
Department of Health
Division of Vital Statistics
CERTIFICATE OF DEATH

1. PLACE OF DEATH:

County Darke
Registration District No. 302
File No. 8666
Township Harrison [Inked Out]
Primary Registration District No. 2317
Registered No. 6
Village New Madison
No. Blank
Street Blank
Ward Blank
City Blank

Length of Residence in City or Town where death occurred
Years Blank
Months 18
Days Blank

How Long in U.S. If of foreign birth? Blank

2. FULL NAME
MARTIN E[ARL] HARRELL
Residence Blank
Did Deceased Serve in U.S. Navy or Army? Army

PERSONAL AND STATISTICAL PARTICULARS

3. SEX Male
4. COLOR / RACE White

5. MARITAL STATUS Married
5a. SPOUSE Anna [Elizabeth DeLANEY] Harrell

6. DATE OF BIRTH Sept 8, 1889
7. AGE 44 Years, 04 Months, 29 Days

OCCUPATION
8. Trade, Profession Physician
9. Industry in which work was done 9294
10. Date last worked @ Occupation Blank
11. Total years spent in Occupation Blank

12. BIRTHPLACE
City or Town Blank
State or Country Ind[iana]

FATHER
13. Name
Thomas [Tighlman] A[shley] Harrell
14. Birthplace
City or Town Blank
State or Country Ind[iana]

MOTHER
15. Maiden Name
Charlotte [Elizabeth] Harrison
16. Birthplace
City or Town Blank
State or Country Ind[iana]

17. INFORMANT
O[tho] G[lenn] Harrell
Address Kokomo, [Howard Co.] Ind[iana] RFD

18. BURIAL, CREMATION or REMOVAL
Place Kokomo, [Howard Co.] Ind[iana
Date Feb[ruary] 9, 1933

19. UNDERTAKER
Stritz? & Sands
Address New Madison, Ohio

19a. Was body embalmed Yes
Embalmer's No. 1293a?

20. FILED Feb[ruary] 15, 1933

Signature Irene Mitchell - Registrar

21. DATE OF DEATH Feb. 7, 1933

22. I HEREBY CERTIFY, That I attended deceased from ____Blank___, 19__,to _____Blank_____, 19__. I last saw H__ alive on ____Blank_____, 19__.

Death is said to have occurred on the date above at 9.30 a.m.

The PRINCIPAL CAUSE OF DEATH and related causes of importance in order of onset were as follows:

Accidental by taking an overdose of chloroform to relieve pain in chest

CONTRIBUTORY CAUSES of importance not related to principal cause: BLANK

Name of Operation: Blank
Date of: Blank
What test confirmed diagnosis? Blank

23. If death was due to external causes (violence) fill in also the following:
Accident, suicide, or homicide? Blank
Date of Injury Blank
Where did injury occur? New Madison, Darke County, Ohio
Specify whether injury occurred in industry, in home, or in public place: Home
Manner of injury: Inhaling Chloroform
Nature of injury: Blank

24. Was disease or injury in any way related to occupation of deceased? Blank
If so, specify: Blank

Signature: Raymond J Marke(r?s?), Coroner (M.D. is inked out)
Date Blank
Address Versailles, Ohio

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