| 1. PLACE OF DEATH |
Name of city or place Essondale, Coquitlam
Street or Road Provincial Mental Hospital |
| 2. LENGTH OF STAY |
In Municipality where death occurred 4 years
In Province 36 yrs. In Canada (if immigrant) life |
| 3. PRINT FULL NAME OF DECEASED | Brown Ernest Clarence |
| 4. PERMANENT RESIDENCE OF DECEASED |
Name of city or place Ruskin, Maple Ridge
Street or road R.R.1 Nil |
| 5. Sex | Male |
| 6. Citizenship | Canadian |
| 7. Racial Origin | English |
| 8. Single, Married, Widowed or Divorced | Married |
| 9. BIRTHPLACE | Manitoba |
| 10. DATE OF BIRTH | December 1 1887 |
| 11. Age | 70 Years |
| 12. Trade, profession or kind of work as logger, fisherman, office clerk etc. | Farmer |
| Kind of industry or business, as logging, fishing, bank, etc | Mixed farming |
| 13. Date deceased last worked at this occupation | 1945 |
| 14. Total yrs. spent in this occupation | unknown |
| 15. If married or divorced give name of husband or maiden name of wife of deceased | Queechy Leh Hallis |
| 16. Father's Name | Brown Alfred |
| 17. Maiden Name of Mother | Dodge Mary |
| 18. Birthplace | Father - Ontario---Toronto Mother - Ontario--Sutton |
| 19. I certify the foregoing to be true and correct to the best of my knowledge and belief |
Given under my hand at Mission City, this 19th. day of February 1958
Signature of informant ??? Relationship to deceased Wife Address of informant 2026 Kaptey Rd. R.R.#2. New Westminster, B.C. |
| 20. Burial, Cremation or Removal |
Burial Date February 19th. 1958.
Place of Burial or Cremation Mission Name of Cemetery Hatzic |
| 21. Undertaker Name | Mission Funeral Home Ltd. Address P.O. Box 176 Mission City B.C. |
| 22. DATE OF DEATH | February 16 1958 |
| 24. I HEREBY CERTIFY | that I attended deceased from January 7 1958 to February 16 1958 and last saw him alive on Feb. 14 1958 |
| Cause of Death |
Bact. Broncho pneumonia
dur to Fracture L. greater? trochantes?
Chronic Brain Syndrome due to Cerebial Aeterio schosis |
| 24. If a woman, was the death associated with pregnancy ... | |
| 25. Was there a recent surgical operation? | no |
| 26. If a violent death, .... | |
| 27. |
Signed by ??? Designation ??? M.D. or Coroner
Address Essondale, B.C. Date February 17 1958 |
| 28. Print name of Doctor or Coroner, whose signature appears above | A. Sleigh,, M.D. |
Source: Royal BC Museum