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B.P.O. Elks National Home - Medical Record
Name, Chas W. Sixbury
Lodge, Watertown, N.Y.
Date of Entry, Dec. 10th 29
Age, 67 Years
Date and Place of Birth, Mch 31st 1862 - N.Y. Single
Name of father and place of birth, Peter Sixbury - N.Y.
Maiden Name of mother and place of birth, Lavanche Vebber, N.Y.
Occupation, Bricklayer & mason
Occupations in past, same
Denomination, none
Has there ever been any Insanity, Consumption, Cancer, Epilepsy, Gout, Rheumatism amongst parents, uncles or aunts?
State, no
What is your habit as regards the use of malt liquors and other alcoholic beverages?
State, Have drank some - all my life
Have you ever taken any special treatment for alcoholism? no
Do you now use, or have you ever used, opium, chloral, cocaine, or other narcotic drugs? no
Have you been successfully vaccinated? yes
When last? yrs ago
Are you ruptured? If so, describe: no
Have you ever undergone any surgical operation? no = fell off load of hay 2 yrs ago - hurt left shoulder & neck
State rate of pulse and quality. 96 fast & ______? Is it intermittent or irregular? no
Are ther any indications of Heart disease? yes myocardial ______?
Blood pressure Syst. 110 Dias. 76
Are there indications of Disease of the Organs, of Respiration? no
Do the abdominal organs appear free from disease? yes
Any past or present history of Bladder trouble? Frequent urination
Height, 6 ft, ___in.
Weight, Lbs. 176
Color of eyes, Blue
Color of hair, Gray
Any distinguishing marks on body? none
General remarks to member's present state of health: Health poor - bad heart & rhumatism of left shoulder & n___?
Probationer - May 10th 1930 made permanent
Name of close relatives, Fred E. Sixbury - Watertown N.Y.
Desired place of burial, Elks Rest - Bedford
(To Member)--Having read the answers given by you to the Physician. Are they true to the best of your knowledge and belief?
(Sign Member's name here.) Chas. W. Sixbury
Date examination was made, Dec 10th 29
J A Ruckes, [Rucker?] M.D., Physician To Elks Home
Expired November 17, 1941 7 a.m.
Cause: Myocardial failure |
