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DEATH
CERTIFICATE
ELIZA JANE COLLINS
Date 04 July 1940
Cert: 17477
Place of Death: County: Knott City or
Town: Vest
Name of Hospital or Institution: (blank)
Length of stay in hospital or community: (blank)
Usual Residence of Deceased: State: Ky.
County: Knott
City or Town: Rural
Full Name: Eliza Jane COLLINS
If Veteran Name War: (blank)
Social Security No.: (blank)
Sex, Color or Race, Marital Status: Female, White, Widowed
Husband or Wife of: (blank)
Age of husband or wife if alive: (blank)
Birth date of deceased: September 1855
Age: 85 years, 09 months
Birthplace: (blank)
Occupation: Housework
Industry or business: own home
Father Name: (blank)
Father Birthplace: (blank)
Mother Maiden Name: (blank)
Mother Birthplace: (blank)
Informant/Address: Jason RICHIE, Vest, Ky.
Burial Place: Vest, Ky.
Date: 05 July 1940
Signature of funeral director/Address: (blank)
Date received by local registrar: 26 July 1940
Registrar's Signature: Macie Miller
Date of Death: 04 July 1940
I hereby certify that I attended deceased from May 1940 to
about 04 July 1940, that I last saw her alive on about 15 June
1940, and that death occurred on the date stated above at 7
p.m.
Immediate cause of death: Flue and weak heart from
mitral regurgitation
Duration: 02 months
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: Mark Dempsey, M.D., Hindman, Ky.
Date signed: 05 July 1940
Transcribed by Debbie Tamborski, 17 August 2010 |
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