| 1. PLACE OF DEATH
A. COUNTY
Prince George's MARYLAND |
2. USUAL RESIDENCE (Where deceased lived, If institution: Residence
before admission)
a. STATE b.
COUNTY
Maryland Prince
George's |
| b. CITY OR TOWN (If outside corporate limits, write RURAL and give
nearest town)
Clinton
c. LENGTH OF STAY in 1b
D.O.A. |
c. CITY OR TOWN (If outside of corporate limits, write RURAL
and give nearest town)
Clinton 07 |
| d. NAME OF HOSPITAL OR INSTITUTION (If not in hospital,
give street address)
Southern Maryland Medical Center |
d. STREET ADDRESS
Woodyard Road 1
e. IS RESIDENCE ON A FARM?
Yes [] No [X] |
| 3. NAME OF DECEASED (Type or print)
William Brack HONEYCUTT |
4. DATE OF DEATH
October 5 1961 |
| 5. SEX
Male
6. COLOR OR RACE
White
7. MARRIED |
8. DATE OF BIRTH
September 13, 02 (1902)
9. AGE (In years last birthday)
59 yrs. |
| 10a. USUAL OCCUPATION (Give kind of work done during
most of working life, even if retired)
Skilled Laborer
10b. KIND OF BUSINESS
Newspaper |
11. BIRTHPLACE
North Carolina
12. CITIZEN OF WHAT COUNTRY
U.S.A. |
| 13. FATHER'S NAME
A.L. HONEYCUTT |
14. MOTHER'S MAIDEN NAME
Hattie OVERCASH |
| 15. WAS DECEASED EVER IN U.S. ARMED FORCES?
Yes
(If yes, give war or dates of service)
Unknown |
16. SOCIAL SECURITY NO.
579-03-2975
17. INFORMANT
William HONEYCUTT
(Note: I have chosen to leave off address due to privacy reasons) |
| 18. CAUSE OF DEATH
Part 1. Death was caused by:
Immediate
Cause (a) Acute congestive heart failure |
Due to
(b) Cardiovascular renal disease |
| 19. WAS AUTOPSY PREFORMED?
Yes [] No [X] |
|
| 21. I certify that I took charge of the remains described above,
held an Autopsy [] Inspection [X] Inquiry [X] and in my opinion
death resulted from Natural Causes [X] Accident [] Suicide
[] Homicide [] Undetermined manner []
ACTUAL SIGNATURE
James I. BOYD M.D. Deputy Medical Examiner
EXAMINER'S NAME (Type) James I. BOYD
DATE SIGNED 10/5/61 |
|
| 22a. BURIAL, CREMATION, REMOVAL (Specify)
Burial
22b. DATE THEREOF
10/9/61 |
22c. NAME OF CEMETERY OR CREMATORY
Trinity Memorial Gardens
22d. LOCATION (City, town, or country) (State)
Waldorf, Md. |
| 23. FUNERAL DIRECTOR
W.W. Chambers Co.
ADDRESS
Riverdale, Md. |
24a. REC'D BY REGISTRAR
DATE Oct 9 '61
24b. REGISTRAR'S SIGNATURE
Arthur S. KRAUS |
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