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Death Certificate of Charles W. Montgomery

Death Certificate of Charles W. Montgomery:

State of Colorado
Standard Certificate of Death
Bureau of Vital Statistics
Dept. of Commerce
Bureau of the Census

Registrar's no.: 9 Dist: ?
1. Place of Death:
(a) County: Larimer
(b) City or town: Fort Collins
(c) Name of hospital or institution: Larimer County Hospital
(d) Length of stay: in hospital or institution: about 6 hrs.
In this community: 40 yrs.
2. Usual Residence of Deceased:
(a) State: Colorado
(b) County: Larimer
(c) City or town: Fort Collins
(d) Street No.: 257 Linden
3(a) Full Name: Charles William Montgomery
4. Sex: Male
5. Color or race: W
6(a). Single, Widowed, married, divorced: Married
(b). Name of husband or wife: Lyle Montgomery
(c). Age of husband or wife if alive: 58 years
7. Birth date of deceased: January 17 1866
8. Age: 75 years, 11 months, 26 days
9. Birthplace: Lynchberg, Ohio
10. Usual occupation: Watchman
11. Industry or business: Sugar Factory
Father:
12. Name: John Montgomery
13. Birthplace: Ohio
Mother:
14. Maiden name: Mary Ann Simmons
15. Birthplace: Ohio
16.(a). Informants own signature: Mrs. Lyle Montgomery
(b). Address: 257 Linden
17.(a). Burial
(b). Date thereof: 1-16-42
(c). Place: burial or cremation: Grandview Cemetery, Fort Collins, Day Funeral
18.(a). Signature of funeral director: Edna B. Rozel?
(b). Address: Fort Collins, Colo.
19. (a). 1/15/1942
(b). Elsie M. Watts
20. Date of death: Month: January, day: 13, year: 1942, hour: 5, minute: 15 P.M.
21. I herebyy certify that I attended the deceased from: Jan. 13, 1942 - Jan. 13, 1942 that I last saw him alive on: Jan. 13, 1942 and that death occured on the date and hour stated above. Immediate cause of death: Coronary Occlusion Duration: 1 day due to: Arteriosclerosis
23. Signature: G. M. Merrill (M.D. or other) Address: Fort Collins Date signed: 1/13/42

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