Date 28 December 1940
Cert: 02301
Place of Death: County: Knott City or Town: Smithsboro
Name of Hospital or Institution: (blank)
Length of stay in hospital or community: 09 months
Usual Residence of Deceased: State: Ky. County: Knott
City or Town: Smithsboro
Full Name: Georgi M. ADAMS
If Veteran Name War: (blank)
Social Security No.: 407-10-0659
Sex, Color or Race, Marital Status: Male, White, Single
Husband or Wife of: (blank)
Age of husband or wife if alive: (blank)
Birth date of deceased: 05 April 1905
Age: 35 years, 08 months, 23 days
Birthplace: Brinkley, Ky.
Occupation: Miner
Industry or business: (blank)
Father Name: Solomon ADAMS
Father Birthplace: Letcher Co.
Mother Maiden Name: Celia PARKS
Mother Birthplace: Marion, Va.
Informant/Address: Celia ADAMS, Smithsboro, Ky.
Burial Place: Sassafras
Date: 29 December 1940
Signature of funeral director/Address: (blank)
Date received by local registrar: 23 January 1941
Registrar's Signature: Macie Miller
Date of Death: 28 December 1940
I hereby certify that I attended deceased from (blank) to (blank), that I last saw him alive on (blank), and that death occurred on the date stated above at (blank)
Immediate cause of death: T. B.
Duration: 02 years
Due to: (blank)
Major findings of operations: (blank)
Accident, suicide, or homicide: (blank)
Date of occurrence: (blank)
Where did injury occur: (blank)
While at work: (blank)
Means of injury: (blank)
Signature & Address: J. W. Duke, Hindman
Date signed: (blank)
Transcribed by Debbie Tamborski, 16 August 2010