| PERSONAL AND STATISTICAL PARTICULARS. |
MEDICAL CERTIFICATE OF DEATH |
| 3. Sex. Male 4. Color or Race. White |
16. Date of Death.
10-2-1924 |
| 5. Single, Married, Widowed, or Divorced.
Widowed. |
17. I HEREBY CERTIFY, That I attended deceased from 5-24,
1924 to 10-1, 1924. |
| 5a. If married, widowed, or divorced
Husband of
(or) wife of.
(Blank) |
That I last saw him alive on 10-1-1924 and that death occured
on the date stated above, at 9 p.m. |
| 6. Date of birth. April 22, 1881 |
The CAUSE OF DEATH was as follows.
Cancer of Liver
Duration of 6 mos. |
| 7. Age
81 Years |
18. Where was disease contracted if not at place
of death?
(Blank) |
| 8. Occupation of deceased
(a) Trade, Profession, or particular kind of work.
Farming.
(b) General nature of industry, business, or establishment
in which employed (or employer)
(Blank)
(c) Name of employer.
(Blank) |
Did an operation precede death?
No
Was there an autopsy? No |
| 9. Birthplace (city or town)
(Blank)
(State or country) Stanly Co. NC |
(Signed) J.I. CAMPBELL, M.D.
(Address) Norwood, NC |
| 10. Name of Father.
Henry COOPER |
19. Place of Burial, Cremation, or Removal.
Silver Springs Church |
| 11. Birthplace of Father (city or town)
(Blank)
(State or country) Stanly Co. NC |
Date of Burial
10/3/1924 |
| 12. Maiden Name of Mother.
Lucinda HUDSON |
20. Undertaker
Morgan Furn Co.
(Address) Albemarle, NC |
| 13. Birthplace of Mother (city or town)
(Blank)
(State or country) Anson Co. NC |
|
| 14. Informant. T.L. COOPER
(Address)
(Blank) |
|
| 15. Filed.
1/10/1925
A.A. THOMPSON, Registrar |
|
You
are our 1106 visitor since the counter
was installed on 17 September 2000.