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DEATH
CERTIFICATE
POLLY ANN CORNETT
Date 04 February 1940
Cert: 17479
Place of Death: County: Knott City or Town:
Carrie
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: Carrie
Full Name: Polly Ann CORNETT
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: (blank)
Age: 82 years
Birthplace: Ky.
Occupation: House wife
Industry or business: (blank)
Father Name: Edward DAVIDSON
Father Birthplace: Ky.
Mother Maiden Name: Liza WALKER
Mother Birthplace: Ky.
Informant/Address: (blank)
Burial Place: Hill Cem.
Date: 06 February 1940
Signature of funeral director/address: William
S. Norris, Hazard, Ky.
Date received by local registrar: 09 July 1940
Registrar's Signature: Macie Miller
Date of Death: 04 February 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: paralysis
Duration: (blank)
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, M.D., Hindman, Ky.
Date signed: 09 July 1940
Transcribed by Debbie Tamborski, 17 August 2010 |
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