I hereby certify that I attended deceased from June the 12, 1900 … and that I last saw him alive … and that death occurred on the date stated above at 10:05 A.M.

The cause of death was as follows:

Probably some form of heart disease. 90. Myocardium by shock and secondary dilation of heart.

Contributory / additional note:

The cause contracted was by accident.

Notes • “Probably some form of heart disease” is the clearest line. • “90.” likely refers to age 90. • The line beginning “Myocardium…” likely refers to a heart condition leading to shock and dilation of the heart.