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DEATH
CERTIFICATE
INFANT CALHOUN
Date 24 September 1940
Cert: 21959
Place of Death: County: Knott Co. City or Town:
Lackey, Ky.
Name of Hospital or Institution: Stumbo Memorial Hospital
Length of stay in hospital or community: (blank)
Usual Residence of Deceased: State: Ky. County:
Pike
City or Town: Joe nancy, Ky.
Full Name: Infant CALHOUN
If Veteran Name War: (blank)
Social Security No.: (blank)
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: (blank)
Age: 10 minutes
Birthplace: Lackey
Occupation: (blank)
Industry or business: (blank)
Father Name: Enoch CALHOUN
Father Birthplace: Pike Co.
Mother Maiden Name: Martha CAUDILL
Mother Birthplace: Pike Co.
Informant/Address: Enoch CALHOUN, Joe Nancy, Ky.
Burial Place: Joe Nancy, Ky.
Date: 26 September 1940
Signature of funeral director/Address: G. D. Ryan, Martin, Ky.
Date received by local registrar: 30 September 1940
Registrar's Signature: Macie Miller
Date of Death: 24 September 1940
I hereby certify that I attended deceased from 24 September
1940 to
24 September 1940, that I last saw him alive on 24 September
1940, and that death occurred on the date stated above at
8:30 p.m.
Immediate cause of death: Failure (illegible)
Duration: (blank)
Due to: Congenital Debility
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: W. L. Stumbo, Lackey, Ky.
Date signed: (blank)
Transcribed by Debbie Tamborski, 16 August 2010 |
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