| PERSONAL AND STATISTICAL PARTICULARS |
MEDICAL CERTIFICATE OF DEATH |
| 3. Sex. Female 4. Color Or Race 5.
Single, Married, Widowed, or Divorced. Widow |
21. Date Of Death (month, day, and year)
6-9.1934 |
| 6. Date of Birth. Aug 12th |
22. I hereby Certify, That I attended deceased from 6/1 of 1930
to 6-8-1934. |
| 7. Age. 84 Years |
I last saw (Blank) alive on (Blank) death is said to have occured
on the date stated above, at (Blank)m. |
| Occupation.
8. Trade, profession, or particular kind of work done, as spinner,
sawyer, bookkeeper, etc. Housework.
9. Industry or business in which work as done, as silk mill, saw
mill, bank, etc. Blank.
10. Date deceased last worked at this occupation (month and year)
1929.
11. Total time (years) spent in this occupation. Life. |
The prinicpal cause of death and related causes of importance in order
of onset were as follows:
Clear Mgscarditis
Date of Onset. (Blank)
Contributory causes of importance not related to principal cause:
(Blank) |
| 12. Birthplace. (city or town)
Blank.
(State of country) Stanly |
Name of operation. None
What test confirmed diagnosis? - |
| Father
13. Name. Robert HINSON |
23. If death was due to external causes (violence) fill
in also the following: Accident, suicide, or homicide? No.
|
| 14. Birthplace (city or town) Blank
(State or country) Stanly |
Date of Injury. (Blank)
Where did injury occur? Albemarle R5 |
| Mother
15. Maiden Name. Caroline HATHCOCK |
Specify whether injury occured in industry, in home, or in public
place. (Blank) |
| 16. Birthplace (city or town) Blank
(State or Country) Stanly |
Manner of injury. -
Nature of injury. (Blank) |
| 17. Informant. Mrs. Isabell BURRIS
(Address) Albemarle #1 |
24. Was disease or injury in any way related to occupation
of deceased? If so, specify. (Blank) |
| 18. Burial, Cremation, Or Removal
Place. Silver Springs Date. 6-10, 1934 |
Signed. J. I. COmp??? M.D.
(Address) Norwood NC |
| 19. Undertaker. Morton Furniture Co.
(Address) Norwood, N.C. |
|
| 20. Filed. July 6, 1934 Note: Author is unable
to make out the name of the Registrar. |
|
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