| Registration Dist, No | 375472 |
| Certificate Number | 36 |
| Home (usual residence) of Deceased | |
| State | NC |
| County | Gates |
| City or Town | |
| Street or RFD | |
| Is place of residence in corporate limits? | |
| If foreign born, how long in USA? (years) | |
| Place of death | |
| County | Gates |
| Township | Hall |
| City or town | Eure |
| Street, Hospital or Institution | |
| Length of stay in hosptial or Institution | |
| In this community (yrs. mos, or days) | |
| Full Name | Wm. Henry Ballard |
| If Veteran, Name War | |
| Social Security Number | |
| Sex | Male |
| Color or race | Colored |
| Single, Married, Widowed or Divorced | Married |
| Name of husband or wife | |
| Age of husband or wife if alive (years) | |
| Birth date of deceased | |
| Age (Years-Months-Days) | 41yrs |
| If less than one day (hrs. mins) | |
| Birthplace | Gates Co., NC |
| Usual Occupation | Farmer |
| Industry or Business | |
| Father's name | Anderson Ballard |
| Birthplace of father | Gates Co. |
| Mother's maiden name | Ronie Bait |
| Birthplace of mother | Gates Co. |
| Date of death (Mon-day-year-time) | Mar. 19, 1927 |
| Physician attended to and from dates | Mar. 12, 1927-Mar. 18, 1927 |
| Last Seen | Mar. 18, 1927 |
| Immediate cause of death | Pneumonia |
| Duration | 8dys |
| Due to | |
| Due to | |
| Other conditions | |
| Major findings of operations | |
| Of Autopsy | |
| Accident, suicide, or homicide | |
| Date of occurance | |
| Where did this injury occur? | |
| Place of injury | |
| At work? | |
| Means of injury | |
| Doctors signature | T. L. Carter |
| Address | Gatesville, NC |
| Date signed | 3-19-1927 |
| Informants signature | Andrew Cross |
| Address | Eure, NC |
| Burial, cremation or removal | Burial |
| Date | Mar. 20, 1927 |
| cemetery | Ballard Cemetery |
| location | |
| Funeral director | C. T. Ellis |
| address | Gatesville, NC |
| Filed | Dec. 4, 1928 |
| Registrar | Mrs. J.B. Brown |
| Comments | |
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